Lecture 11 (GU)- Exam 4 Flashcards

Question

Asymptomatic Bacteriuria * Pyuria with the absence of bacterial growth (sterile pyuria) and presence of the clinical picture of UTI usually suggests what? * Alternatively, 30% of women with acute dysuria do not have what? * 30% of those with mild bladder limited symptoms have what?

Answer 1

* Pyuria with the absence of bacterial growth (sterile pyuria) and presence of the clinical picture of UTI usually suggests chlamydial, gonococcal, herpes simplex infection * Alternatively, 30% of women with acute dysuria do not have significant bacteriuria * 30% of those with mild bladder limited symptoms have clinically silent upper tract disease

Answer 2

ACOG: Screening for and treatment of asymptomatic bacteriuria is not recommended in non-pregnant, premenopausal women * you should treat Preg patients and renal transplant patients

Answer 3

* Beginning in week 6 and peaking during weeks 22-24, approx. 90% develop ureteral dilatation; increased bladder volume and decreased bladder tone contribute to urinary stasis and reflux. * Associated with premature labor and delivery, increased fetal loss, and prematurity * Pregnant women with overt pyelonephritis should be admitted for parenteral therapy

Answer 4

* Ampicillin: historically drug of choice, but E. coli increasingly resistant * Cephalexin (Keflex) * Nitrofurantoin (Macrobid) * Sulfonamides should be avoided near term because of risk of kernicterus in newborn * Avoid fluoroquinolones or tetracyclines

Answer 5

* Most common nosocomial due to **Foley** * Bacteriuria develops in at least 10-15% of hospitalized pts with indwelling urethral catheters * Risk of infection about 3-5 % per day of catheterization * UTI accounts for 15% of nosocomial bacteremias

Answer 6

* Chronic indwelling catheters * Open drainage (vs. closed bag drainage) * Interruption of closed drainage * Use of broad-spectrum antibiotics

Answer 7

* Symptoms include fever, chills, back, or flank pain, nausea and vomiting; urine may show **WBC casts** * A clean-catch or catheterized urinalysis with culture and sensitivity identifies the pathogen and determines appropriate antimicrobial therapy

Answer 8

* Elderly patients may have altered mental status or hypotension with sepsis or Acute renal failure * Gram’s stain of urine in hospitalized patients will guide therapy; * All patients should have repeat culture 1 to 2 weeks after treatment and oral antibiotics are typically continued through the results of that culture

Answer 9

* Escherichia coli * Klebsiella or Enterobacter (commonly hospital acquired) * Proteus, Morganella, or Providencia (Urea-splitting Proteus common with staghorn renal calculi) * Pseudomonas aeruginosa (indwelling catheters, relapsing after multiple antibiotic courses) * Staphylococcus saprophyticus * Enterococcus

Answer 10

Same for UTI seen previously, as well as: * Pregnancy * diabetes mellitus * Polycystic * hypertensive kidney disease * insult to the urinary tract from catheterization, infection, obstruction or trauma

Answer 11

* Physical exam: CVAT/CMT/PID/DRE * CBC with leukocytosis with left shift * UA shows pyuria, bacteriuria, and possible hematuria. WBCs casts can be shown. * Urine culture * If very complicated pyelonephritis, then renal U/S may show hydronephrosis secondary to obstruction. * In a male, IVP or VCUG needs to be performed following pyelo ## Footnote * CVAT – costovertebral angle tenderness * CMT 0- cervical motion tenderness * PID – pelvic inflammatory disease * DRE – digital rectal exam

Answer 12

* Empiric IV ABX covering typical expected pathogens for risk factors/age group (Rocephin or Cefepime; adjust based on C/S) * Treat with ESBL and MRSA coverage-Imipenem or meropenem or doripenem plus vancomycin

Answer 13

* Most likely admission, esp. with fever (eg, >38.4°C/>101°F) or pain, marked debility, or inability to maintain oral hydration or take oral medications. * Additionally, inpatient management is warranted when urinary tract obstruction is suspected or there are concerns regarding patient adherence. * Oral ABX for outpatient therapy for stable patients only (rare)

Answer 14

* Interstitial cystitis/bladder pain syndrome (IC/BPS) is a condition involving chronic bladder pain or discomfort that can have a profound detrimental impact on quality of life. * Acts like a UTI, but is NOT an infection

Answer 15

from a lack of clear understanding of the etiology of the disorder, symptom variation across patients, and a paucity of high-quality data regarding the efficacy and safety of IC/BPS treatments (eg, few randomized trials, variation in the definition of the condition and outcome measures)

Answer 16

* Suprapubic/pelvic floor pain * Bladder discomfort that is better with voiding * Dysuria, hematuria, frequency * Anterior vaginal wall tn on manual exam * Dyspareunia * Pain at tip of penis for men * Painful ejaculation (2nd to muscular contractions)

Answer 17

* No tests * Treatment: NSAIDs, PT for pelvic floor exercises, amitriptyline * Botox vs sacral neuromodulation vs Urinary diversion surgery * Urology referral * Cystectomy as last resort

Answer 18

* Common cause of pain, infection, and obstruction * DM is a common risk factor

Answer 19

* Urolithiasis – general urological system stone * Nephrolithiasis – in the kidney * Ureterolithiasis – in the ureter ## Footnote Important distinction – nephrolithiasis does not cause symptoms of pain or discomfort as the stones are simply sitting on the renal calyces. Once they drop into renal pelvis and ureter, they cause symptoms

Answer 20

1. Calcium oxalate/Calcium phosphate – 70 - 80 % 2. Calcium phosphate – 15 % 3. Uric acid – 8 % 4. Cystine – 1- 2 % 5. Struvite (UTI) – 1 % 6. Mixed (calcium oxalate and uric acid) – 2%

Answer 21

* Kidney stones are a common problem. * A study based upon the National Health and Nutrition Examination Survey (NHANES) estimated that 19 percent of men and 9 percent of women will be diagnosed with a kidney stone by the age of 70 years. * Most common in non-Hispanic whites then Hispanics * Least common in African American and Asian patients. * Highest in the SE region of USA.

Answer 22

* Animal protein, oxalate, sodium, sucrose, and fructose. * Dietary factors associated with a lower risk include calcium, potassium, and phytate.

Answer 23

* Age, race, body size (wt gain), and environment * Incidence of stone-highest in middle-aged white men, but stones can form in infants as well as in the elderly * Geographic variability, with the highest prevalence in the southeastern United States. * Environmental and occupational influences that may lead to lower urine volume, such as working in a hot environment or lack of ready access to water or a bathroom, are important considerations

Answer 24

* Lower urine volume results in higher concentrations of lithogenic factors and is a common and readily modifiable risk factor * A randomized trial has demonstrated the effectiveness of higher fluid intake in increasing urine volume and reducing the risk of stone recurrence.

Answer 25

* Patients may present with the classic symptoms of renal colic and hematuria. * Others may be asymptomatic or have atypical symptoms such as vague abdominal pain, acute abdominal or flank pain, back pain, nausea, urinary urgency or frequency, difficulty urinating, penile pain, or testicular pain.

Answer 26

CVA tenderness is a red flag for hydronephrosis

Answer 27

* CBC, Chemistry * U/A & Urine culture * **Gold standard**=CT Scan without contrast * Renal U/S (Can only identify stones within in the kidney, proximal ureter or UVJ) - useful to detect hydroureter/hydronephrosis and is a preferred choice in **pregnancy**

Answer 28

* Plain-film (Can only detect LARGE radiopaque stones but will likely miss small stones) – do not use * Intravenous pyelogram (IVP) is rarely indicated (unless looking for uric acid stones. If needed, make sure there is good renal function since contrast is used

Answer 29

Radiopaque and Radiolucent Stones * Uric Acid stones are radiolucent

Answer 30

Urgent decompression of the collecting system with either percutaneous drainage or ureteral stenting is indicated in spetic patients with obstructing stones, bilateral obstrucation with acute kidney injury, and unilateral obstruction with acute kidney injury in a solitary kidney

Answer 31

In a patient who has newly dx urteral stone <5mm and whose sxs are controlled, without sepsis/sirs and with normal renal fxn, observation with periodic evaluation is an option for initial treatment

Answer 32

In patients in whom emergency therapy is not indicated, stone removal may be performed in the presence of persistent obstruction, failure of stone progression, or in the presence of increasing or unremitting colic. In patients who require stone removal, the two most commonly applied techniques are ureteroscopy and shock wave lithotripsy (SWL). Ureteroscopy produces better stone-free rates and a reduced need for retreatment

Answer 33

* All stones should undergo chemical analysis (urinate through strainer) * Outpatient vs Hospitalization based on clinical presentation, V/S, labs * Most stones ≤5 mm in diameter pass spontaneously. * Hx of frequent stones or scarring inside of the ureter lumen inversely affects the size of the stone and chances of spontaneous passage of stone

Answer 34

* Patients with stones larger than 10 mm in diameter, patients with significant discomfort, those with significant obstruction, those with urosepsis/AKI/ nausea/vomiting, or who have not passed the stone after 72hrs should be referred to urology for potential intervention. * Ureteral stent or Percutaneous nephrostomy (Gold standard) should be used if renal function is jeopardized

Answer 35

* Both **tamsulosin** and **nifedipine** have been shown to increase the likelihood of stone passage, with tamsulosin showing slightly better results. * In patients with stones >5 and ≤10 mm in diameter, treatment with tamsulosin for up to four weeks to facilitate stone passage. * Hydration is key! IV or PO depending on clinical presentation * NSAIDs tend to work better than narcotics. * IV ABX for any infected stones

Answer 36

* Risk factors for calcium oxalate stones include higher urine calcium, higher urine oxalate, and lower urine citrate. * This stone type is insensitive to pH in the physiologic range * Excessive calcium intake (>1200 mg/d) should be avoided. * **A thiazide diuretic**, in doses higher than those used to treat hypertension, can substantially lower urine calcium excretion | *

Answer 37

* Calcium phosphate stones share risk factors with calcium oxalate stones, but additional factors include: * Higher urine phosphate levels and higher urine pH (typically ≥6.5) are associated with an increased likelihood of calcium phosphate stone formation. * Calcium phosphate stones are more common in patients with distal renal tubular acidosis and primary hyperparathyroidism ## Footnote Calcium oxalate: Risk factors for calcium oxalate stones include higher urine calcium, higher urine oxalate, and lower urine citrate.

Answer 38

* Uric acid stones; risks are persistently low urine pH and higher uric acid excretion. * Urine pH is the predominant influence on uric acid solubility; therefore, the mainstay of prevention of uric acid stone formation entails increasing urine pH

Answer 39

* Struvite stones may grow quickly and fill the renal pelvis (staghorn calculi).-> Can be due to urea splitting organisms (Proteus) * Struvite stones require complete removal by a urologist * New stone formation can be avoided by the prevention of UTIs ## Footnote Composed of Mag ammonium phosphate

Answer 40

* Cystine excretion is not easily modified * Long-term dietary cystine restriction is not feasible and is unlikely to be successful * Cystine stone prevention is on increasing cystine solubility * May tx with medication that covalently binds to cystine and a medication that raises urine pH.

Answer 41

* Extracorporeal shock wave lithotripsy: may be used to break up larger stones that are less likely to pass spont. May need multiple txts to reduce the size of the stones * Ureteroscopy with/without stent: provides immediate relief to an obstructed or at risk kidney * Percutaneous nephrolithotomy: Most invasive, used for large stone **(over 10mm), struvite** or if other less invasice modalities fail.

Answer 42

* Stretch receptors within the detrusor muscle send a signal to the brain * Brain determines if voiding is appropriate * Detrusor muscle contracts * External urethral sphincter relaxes and voiding is completed

Answer 43

defined as the unintentional leakage of urine at inappropriate times

Answer 44

* The most common type in females * Loss of pelvic support leads to descension of the bladder neck from the intra-abdominal cavity * Painless loss of urine concurrent with Valsalva, cough, laugh, sneeze

Answer 45

Intrinsic sphincteric deficiency (ISD) is a form of stress urinary incontinence that results from a loss of intrinsic urethral mucosal and muscular tone that normally keeps the urethra closed.

Answer 46

* Laxity of pelvic floor muscles (childbirth, surgery, postmenopausal estrogen loss) * Ureethral hypermobility: insufficient support from the pelvic floor musculature and the vaginal connective tissue to the urethra and the bladder neck

Answer 47

Urgency urinary incontinence (UUI)- the most common type males, manifests as a sudden and compelling desire to pass urine that is difficult to defer and is accompanied by involuntary leakage. * Have urgency, freq, small volume voids and nocturia

Answer 48

* **Overactive detrusor muscle** w/ uninhibited contractions * Contractions cause a rise in bladder pressure that overrides the urethral pressure * Patient leaks urine w/o events that increase intra-abdominal pressure * Urge component can be stimulated by running water *

Answer 49

* Occurs when urine is retained in the bladder due to incomplete emptying after an attempt to urinate. Loss of urine with no warning (as in urge) or no triggers (as in stress) Leakage or dribbing when incomp emptying, weak or intermittent urinary stream, heitancy, freq and nocturia. Leakage with position changes * Frequently accompanies injury to the bladder and kidneys. * Caused by detrusor underactivity, bladder outlet obstruction (BOO).

Answer 50

a combination of SUI and UUI, is not common among men. It may be seen when both the bladder and urinary sphincter have impaired function, such as in patients with neurologic disorders (eg, spina bifida, spinal cord injury) or sometimes after prostate surgery or radiation’ or as a result of drug side effect.

Answer 51

* Medications that can increase bladder contractility or exacerbate obstructive effects (Muscarinic agents along with BPH can cause synergistic effect) * Neurologic conditions affecting the brain and its response on hyperactive contractility (stroke, normal pressure hydrocephalus) that can also cause UUI.

Answer 52

prostate surgery (Most common); Spinal cord injury or disease that impairs sphincter function and Medications that can impair it as well.

Answer 53

* BPH * Urethral stricture disease * Neurologic disorders (cauda equina or spinal cord lesions) * Medications that can decrease bladder contractility/cause detrusor underactivity (anticholinergics, sedatives, TCA’s) * Post-op urinary retention

Answer 54

Rectal examination to assess prostate size and consistency for a gross estimate of the degree of benign prostatic hyperplasia (BPH) that could cause bladder outlet obstruction (BOO). Abdominal examination after voiding to: * Assess for a palpable bladder that may be present with incomplete emptying * Assess for an abdominal mass that could cause pressure on the bladder

Answer 55

occurs when the wall between a woman's bladder and her anterior vagina wall weakens and stretches, allowing the bladder to bulge into the vagina

Answer 56

* A urinalysis should be performed for all patients, and urine culture performed if a UTI, glycosuria, or hematuria is suggested on screening. * We do not routinely check renal function unless there is concern for severe urinary retention resulting in hydronephrosis. Other laboratory testing is determined by signs or symptoms elicited on history and physical exam.

Answer 57

* Bladder stress test * Post-void residual test * Urodynamic studies-overflow

Answer 58

* Measure volume of urine left in bladder after voiding by catheter or most typically bladder scanner * Normal bladder holds up to 500ml pre-void * <50ml is normal in adults (<100 in 65+yo) postvoid * >300ml – insert foley

Answer 59

* Lifestyle modifications: Weight loss (esp. in SUI), dietary changes, constipation treatment, smoking cessation. * All but overflow: Pelvic floor muscle exercises (Kegel)

Answer 60

* SUI: no FDA meds. Duloxetine, imipramine. Vaginal pessaries * Topical estrogen (Estrace) for vaginal atrophy in post menopausal women * Surgery includes **urethropexy, midurethral slings (Females)**, microwave therapy, transurethral radiofrequency ablation, laser vaporization of prostate, transurethral resection of prostate, and open prostatectomy (Males)

Answer 61

* UUI/OAB: bladder training with antimuscarinic (tropium, darifenaccin) and/or Beta 3 agonist medications (mirabergron, virbegron) (Oxybutynin/terazosin/vesicare) * Overflow: Self-catherization (permanent or temp) * Functional: Treatment of underlying cause

Answer 62

* Last resort surgical options: * Percutaneous tibial nerve -> stimulation * Sacral neuromodulation (Botox)

Answer 63

* Associated abdominal or pelvic pain in the absence of UTI Culture-proven recurrent UTIs (three or more per year or two in six months) * Gross or microscopic hematuria with risk factors for malignancy in the absence of a UTI * Lifelong incontinence or suspected vesicovaginal fistula or urethral diverticula on vaginal examination * Other abnormal physical examination findings (eg, pelvic mass, pelvic organ prolapse beyond the hymen, difficulty self cathing)

Answer 64

* Transient urinary incontinence * Detrusor hyperactivity * Detrusor – underactive or areflexic * Intrinsic sphincter deficiency * Bladder outlet obstruction * Bladder prolapse * Female pelvic floor disorders

Answer 65

* Detrusor underactivity (DU) is reduced strength or duration and/or failure to achieve complete bladder emptying within a normal time span * Voiding phase: straining, hesitancy, weak stream * Storage phase: loss of normal urge to void, reduced urination, nocturia * Post-voiding phase: feeling of incomplete emptying

Answer 66

* Biopsy of detrusor muscle shows axonal degeneration, muscle loss and fibrosis * May coexist with detrusor overactivity (with impaired contractility)

Answer 67

* Mechanical Intrinsic: FB, clot, stones * Wall: Urethral valves (male neonates)spasms, tumor, stricture, fibrosis * Extrinsic: BPH/CA, prostatitis, pregnancy, constipation, fecal impaction * Neuropathic: Spinal cord trauma, GBS, MS * Drug induced: Anticholinergics and antidepressants

Answer 68

* Overactive and underactive bladder * Urinary frequency/nocturia * Stress/urge incontinence * Urinary retention

Answer 69

Dr V: * Antimuscarinics or beta 3 agonist: help increase holding capacity * Alpha blockers may improve bladder emptying in pts who spontaneously void

Answer 70

* Vesicoureteral reflux (VUR) is the retrograde passage of urine from the bladder into the upper urinary tract. * clincal significance: predisposes patient to acute pyelo by transporting bacteria from the bladder to the kidney and recurrent urinary tract infection, which may lead to renal scarring, hypertension and end stage renal disease

Answer 71

* From congenitally incompetent closure of incompetent UVJ which forces urine against the flow upon bladder contraction * Typically found in a newborn

Answer 72

* From abnormally high pressure in bladder that causes UVJ to inadequately close during bladder contraction (inhibiting the urge to void) * Highly associated with BOO (posterior urethral valves)

Answer 73

* Primary VUR is the most common urologic finding in children, occurring in approximately 1 percent of newborns. * The diagnosis of VUR is based upon the demonstration of reflux of urine from the bladder to the upper urinary tract by either contrast voiding cystourethrogram (VCUG) or radionuclide cystogram.

Answer 74

Medical Therapy * Daily ABX prophylaxis * Cotrimoxazole/Nitrofurantoin QHS * Breakthrough infections based on C/S Surgical Therapy * Grades 4/5 OR if recurrent UTI despite prophylactic medical therapy or deterioration of renal function despite treatment

Answer 75

* narrowing of the urethra that obstructs the flow of urine * Urethral strictures are relatively common in men. * The most common etiology is idiopathic in developed countries and trauma in developing countries. * Iatrogenic injuries, such as oversized resectoscope at the time of transurethral surgery and traumatic placement of indwelling urinary catheters, account for 45 percent of all cases.

Answer 76

Sympotms: Chronic obstruction sx and recurenet UTIs * Abdominal Pain * Urinary frequency/Urgency * Difficulty urinating * Dysuria * Hematuria * Hematospermia Dx: VCUG Tx: Meato/urethroplasty or excision/reanastomosis (endoscopic txt)

Answer 77

* Dilation: Stretching the stricture with a medical instrument. This is one of the simplest treatments but often needs to be repeated periodically as strictures tend to recur. * Urethrotomy: An internal cut is made in the stricture with a special instrument inserted through the urethra. This procedure is typically done under local or general anesthesia

Answer 78

* Urethral Stents: Sometimes a stent (a small tube) can be placed in the urethra to keep it open. This approach is less common and usually reserved for specific situations. * Urethroplasty: This is a surgical repair of the stricture and is considered when other treatments fail or the stricture is long. The affected part of the urethra may be removed, and the urethra is reconstructed. Tissue grafts from the patient or a flap of skin may be used to reconstruct the urethra.

Answer 79

* Urethral prolapse is a red papule at the urethral meatus that is seen in premenarchal or postmenopausal individuals. * Dysuria may be present. The lesion is differentiated from the urethral caruncle by its presentation as a circumferential, bright red nodule around the meatus, making a donut shape around the urethral orifice.

Answer 80

Urethral caruncle is most common in a post-menopausal female and is a fleshy benign outgrowth of posterior urethral meatus. Sometimes presents with bleeding.

Answer 81

* Premenarchal girls with symptomatic urethral prolapse can be treated with topical estrogen therapy (eg, Premarin cream or Estrace cream 0.01%) same as postmenopausal women with this problem. * Sitz baths twice daily may also be helpful. Topical estrogen cream is applied twice daily after the sitz bath for two weeks, then the urethra is reassessed and treatment is continued if the prolapse has not resolved and is still present.

Answer 82

The prolapse will usually resolve within a few weeks of topical estrogen treatment but can sometimes take longer. Rarely, the distal urethra can be necrotic, and if so, it may require surgery. If there is persistence of the prolapse, assessment for a urethral polyp may be indicated.

Answer 83

* Urethral meatal stenosis is almost always a condition of circumcised boys. It is thought that stenosis develops from irritation of the newly exposed meatus, which usually occurs on the ventral lip. * Typical presentations occur after toilet training and include an upward deflected urine stream, inability to direct the stream into the toilet, or a small stream with prolonged voiding time.

Answer 84

* Often boys will push their penis between their legs to direct the upward pointed urinary stream into the toilet. Other less common presentations include episodes of gross hematuria, dysuria, and UTI. * Treatment involves office or operating room meatotomy where a few millimeters of the ventral lip of the meatus are divided. Sutures are then usually used to reapproximate the cut edges.

Answer 85

congenital displacement of urinary duct on the underside of penis instead of tip. Degree can vary from just under the rim of head of penis to the scrotum. Glans size can vary as well. Dx: During newborn exam * Abnormal foreskin resulting in an incomplete closure around the glans leading to the appearance of a dorsal hooded prepuce. * Abnormal penile curvature (chordee). * Ectopic urethral meatus or blind ending urethral pit

Answer 86

* Congenital: abnormal VENTRAL placement of the uwethral opening, penile curve and abnormal foreskin development * Patho: Failure of urogenital folds to fuse * Txt: NOT circumcised in neonatal period because foreskin may be used to repair the defeat. Surgery usually between 6m-1yo

Answer 87

* Chordee affects the cosmetic appearance of penis. * It is characterized by formation of thick fibrous tissue bands that pulls the penis sideward; thereby making it look curvy or bent. It is noteworthy that the curviness of penis becomes particularly prominent during penile erection. * This condition is frequently observed in young males who have hypospadias. * Tx: Surgical correction

Answer 88

* Congenital abnormality in which the urethra is on upper surface (DORSAL) of the penis * Patho: failure of midline penile fusion * Often assoicated with bladder exstrophy * Similar Tx as to hypospadias * Correct urethral duct and chordee if present

Answer 89

* Definition: This occurs when a child has never been consistently dry at night for an extended period, typically defined as six months or longer. In other words, the child has never achieved nighttime bladder control * Cause: Developmental Delay or Genetics

Answer 90

Definition: This occurs when a child or adult who has been consistently dry for at least six months starts wetting the bed again. Causes: * CKD, LUTS, urethral valves * Constipation, Pinworms * Sickle Cell Disease * Seizures * DM/DI * OSA

Answer 91

PE is Usually normal * Screen for daytime hydration patterns and voiding patterns (some kids tend to not drink at school, but drink most fluids 4-5hrs prior to bedtime at home) U/A should be performed.

Answer 92

Daytime incontinence, urgency, holding measures, increased (≥8 times/day) or decreased (≤3 times/day) voiding frequency (possible bladder dysfunction) * Weak stream, use of abdominal pressure, continuous incontinence, micturition in more than one phase (possible neurogenic bladder or anatomic abnormalities) * Proteinuria, nausea, weight loss, or fatigue (possible kidney disease) * Excessive thirst, need for nighttime drinking (possible polydipsia or kidney disease)

Answer 93

Treatment includes CBT (motivational therapy) and bladder training-> enuresis alarm and if failed -> then drug therapy: desmopressin (DDAVP).

Answer 94

* Cryptorchidism is the most common congenital abnormality of the genitourinary tract. * Most cryptorchid testes are undescended, but some are absent (due to agenesis or atrophy).

Answer 95

* Potential complications and sequelae of true undescended testes include inguinal hernia, increased risk of testicular torsion and testicular trauma (for intracanalicular testis – from compression against the pubic bone), subfertility, and malignant transformation. * Potential complications of ectopic testes include blunt trauma from compression against the pubic bone and decreased spermatogenesis

Answer 96

The presence of unexplained (or painless) hematuria in individuals over 35 years of age requires evaluation for possible malignancy.

Answer 97

* Bladder cancer is the most common malignancy involving the urinary system. * Urothelial (transitional cell) carcinoma is the predominant histologic type *