Pestana Chap 12 - Urology

Question 1

In patients of what age do you commonly see testicular torsion? How do they present? What is characteristic of the testis on physical exam? What about the cord?

Answer 1

1) Testicular torsion is seen in young adolescents
2) They have very severe testicular pain of sudden onset, but no fever, pyuria, or history of recent mumps
3) The testis is swollen, exquisitely tender, “high riding,” and with a “horizontal lie”
4) The cord is not tender

Question 2

Is testicular torsion a urologic emergency? What is treatment?

Answer 2

1) This is one of the few urologic emergencies, and time wasted doing any tests is tantamount to malpractice
2) Immediate surgical intervention is indicated. After the testis is untwisted, an orchiopexy is done. Many urologists also fix the other side

Question 3

What is a condition with which acute epididymitis can be confused with? In patients of what age do you see it? How does it present and what is seen on physical exam?

Answer 3

1) Acute epididymitis is the condition with which testicular torsion could be confused
2) It happens in young men old enough to be sexually active
3) It starts with severe testicular pain of sudden onset. There is fever and pyuria, and the testis although swollen and very tender is in the normal position. The cord is also very tender

Question 4

What is acute epididymitis treated with and what test is done to rule out testicular torsion?

Answer 4

Acute epididymitis is treated with antibiotics, but the possibility of missing a diagnosis of testicular torsion is so dreadful that sonogram is done to rule it out

Question 5

What is another urologic emergency besides testicular torsion that is of the urinary tract? Why is it an emergency?

Answer 5

1) The combination of obstruction and infection of the urinary tract is the other condition (besides testicular torsion) that is a dire emergency
2) Any situation in which these two conditions coexist can lead to destruction of the kidney in a few hours, and potentially to death from sepsis

Question 6

What is a typical scenario of obstruction and infection of the urinary tract? What is the treatment?

Answer 6

1) A patient who is being allowed to pass a ureteral stone spontaneously and who suddenly develops chills, fever spike (104 or 105F), and flank pain
2) In addition to IV antibiotics, immediate decompression of the urinary tract above the obstruction is required. This is accomplished by the quickest and simplest means (in this example, ureteral stent or percutaneous nephrostomy), deferring more elaborate instrumentations for a later, safer date

Question 7

In which patients is urinary tract infection (cytitis) common in? How does it present?

Answer 7

1) Urinary tract infection (cystitis) is very common in women of reproductive age, and it requires no elaborate workup
2) They have frequency, painful urination, with small volumes of cloudy and malodorous urine

Question 8

How is urinary tract infection treated? How are more serious infections, like pyelonephritis or any urinary tract infection in children or young men, worked up?

Answer 8

1) Empiric antimicrobial therapy
2) Requires urinary cultures and some kind of “urologic workup” to rule out concomitant obstruction as the reason for the serious infection

Question 9

What is a urologic workup? What are benefits to the traditional urologic workup? What are limitations of this workup? In which patients should it not be conducted?

Answer 9

1) Urologic workup for many years meant an intravenous pyelogram (IVP). The IVP may still be used, but its use has been rapidly replaced by other safer tests in recent years
2) IVP gives excellent views of the kidneys, collecting system, ureters, and to some extent the bladder (it cannot see early carcinomas in the bladder). It provides a good idea of function, both for the renal parenchyma and for the ureters and bladder (reflux)
3) Limitations include potential allergic reaction to the dye, which may be severe, and contraindication in patients with limited renal function
4) It should not be done in patients with a creatinine >2

Question 10

Among the newer exams for urologic workup, which are ideal for renal tumors? For dilitation (i.e., obstruction)? For bladder mucosa and detecting early cancers?

Answer 10

1) CT is ideal for renal tumors
2) Sonograms are a very safe and inexpensive way to look for dilation (i.e., obstruction)
3) Only cystoscopy can look at the bladder mucosa in detail and aid in detecting early cancers

Question 11

How does pyelonephritis present? What testing and treatment are required to be done?

Answer 11

1) Produces chills, high fever, nausea, vomiting, and flank pain
2) Hospitalization, IV antibiotics (guided by cultures), and urologic workup (CT or sonogram) are required

Question 12

In what age patients do you see acute bacterial prostatitis, how does it present, and what is seen on physical exam?

Answer 12

Acute bacterial prostatitis is seen in older men who have chills, fever, dysuria, urinary frequency, diffuse low back pain, and an exquisitely tender prostate on rectal exam

Question 13

What is treatment for acute bacterial prostatitis and care should be taken to not repeat what? What can continued prostatic massage lead to?

Answer 13

1) IV antibiotics are indicated, and care should be taken not to repeat any more rectal exams
2) Continued prostatic massage could lead to septic shock

Question 14

What is the most common reason for a newborn boy not to urinate during the first day of life and what else should be looked for?

Answer 14

Posterior urethral valves (meatal stenosis should also be looked for)

Question 15

What should be done to empty the bladder of a newborn boy with posterior urethral valves? What is the diagnostic test? What will rid of the posterior urethral valves?

Answer 15

1) Catheterization can be done to empty the bladder (the valves will not present an obstacle to the catheter)
2) Voiding cystourethrogram is the diagnostic test
3) Endoscopic fulguration or resection will get rid of them

Question 16

What is hypospadias and is it easily noted on physical exam? What should never be done on a child with hypospadias and why?

Answer 16

1) The urethral opening is on the ventral side of the penis, somewhere between the tip and the base of the shaft. It is easily noted on physical exam
2) Circumcision should never be done on such a child, inasmuch as the skin of the prepuce will be needed for the plastic reconstruction that will eventually be done

Question 17

What should urinary tract infection in children always lead to? What may be the cause?

Answer 17

1) A urologic workup

2) The cause may be vesicoureteral reflux or some other congenital anomaly

Question 18

What symptoms do vesicoureteral reflux and infection produce? How is the infection treated? What is done for the reflux?

Answer 18

1) Burning on urination, frequency, low abdominal and perineal pain, flank pain, and fever and chills in a child
2) Start treatment of the infection with empiric antibiotics first, followed by culture-guided choice
3) Do voiding cystourethrogram looking for the reflux. If found, long-term antibiotics are used until the child “grows out of the problem”

Question 19

Which patients are symptomatic from low implantation of a ureter? How do they present?

Answer 19

1) Low implantation of a ureter is usually asymptomatic in little boys but leads to a fascinating clinical presentation in little girls
2) The patient feels normally the need to void, and voids normally at appropriate intervals (urine deposited into the bladder by the normal ureter), but she is also wet with urine all the time (urine that drips into the vagina from the low-implanted ureter)

Question 20

What should be done to identify the ectopic ureter in low implantation of a ureter? What should be avoided in children for diagnosis? What is the treatment?

Answer 20

1) Careful vaginoscopy should identify the ectopic ureter
2) IVPs are best avoided in children
3) Corrective surgery will follow

Question 21

What is ureteropelvic junction (UPJ) obstruction? How does it present?

Answer 21

1) The anomaly at the UPJ allows normal urinary output to flow without difficulty, but if a large diuresis occurs, the narrow area cannot handle it
2) Thus the classic presentation is an adolescent who goes on a beer-drinking binge for the first time in his life and develops colicky flank pain

Question 22

What is the most common presentation for cancers of the kidney, ureter, or bladder? What are most cases of this presentation commonly caused by?

Answer 22

1) Hematuria
2) Actually most cases of hematuria are caused by benign disease, but except for the adult who has a trace of urine after significant trauma, any patient presenting with hematuria needs a workup to rule out cancer

Question 23

What does the workup of hematuria begin with and continue with?

Answer 23

Begins with CT scan and continues with cystoscopy, which is the only reliable way to rule out cancer of the bladder

Question 24

How does renal cell carcinoma present in its full-blown picture? What will be found on laboratory studies? Why is this picture not commonly seen anymore?

Answer 24

1) Produces hematuria, flank pain, and a flank mass
2) They can also produce hypercalcemia, erythrocytosis, and elevated liver enzymes
3) That full-blown picture is rarely seen nowadays, when most patients are worked up as soon as they have hematuria

Question 25

What test gives the best detail for renal cell carcinoma and what does it look like? What is the only effective therapy?

Answer 25

1) CT gives the best detail, showing the mass to be heterogenic solid tumor (and alerting the urologist to potential growth into the renal vein and the vena cava)
2) Surgery is the only effective therapy

Question 26

Which urologic cancer has a very close correlation with smoking and what does it usually present with? What are patients sometimes mistakenly treated for?

Answer 26

1) Cancer of the bladder (transitional cell cancer in most cases) has a very close correlation with smoking (even more so than cancer of the lung) and usually presents with hematuria
2) Sometimes there are irritative voiding symptoms, and patients may have been treated for urinary tract infection even though cultures were negative and they were afebrile

Question 27

What is the best way to diagnose cancer of the bladder? What should this test be preceded by?

Answer 27

Although cystoscopy is the best way to diagnose these, it should be preceded by CT scan

Question 28

What are therapeutic treatment options for cancer of the bladder? Why is lifelong close follow-up of bladder cancer a necessity?

Answer 28

1) Surgery and intravesical BCG

2) Very high rate of local recurrence

Question 29

How does prostatic cancer correlate to age? How are they usually identified?

Answer 29

1) Prostatic cancer incidence increases with age
2) Most are asymptomatic and have to be sought by rectal exam (rock-hard discrete nodule) and prostatic specific antigen (PSA; elevated levels for age group)

Question 30

What is done for diagnosis of prostatic cancer? What helps to assess extent and choose therapy? What are treatment options?

Answer 30

1) Transrectal needle biopsy (guided by sonogram when discovered by PSA) establishes diagnosis
2) CT helps assess extent and choose therapy
3) Surgery and/or radiation are choices

Question 31

With widespread bone metastases, how is prostatic cancer treated?

Answer 31

Widespread bone metastasis respond for a few years to androgen ablation, surgical (orchiectomy) or medical (luteinizing hormone-releasing hormone agonists, or anti-androgens like flutamide)

Question 32

In what age patients does testicular cancer present in and how does it present? Why is biopsy done with a radical orchiectomy?

Answer 32

1) Testicular cancer affects young men, in whom it presents as a painless testicular mass
2) Because benign testicular tumors are virtually nonexistent, biopsy is done with a radical orchiectomy by the inguinal route

Question 33

What blood samples are taken pre-op for testicular cancer removal? What further surgery may be done in some cases? What other treatment is available in advanced, metastatic disease?

Answer 33

1) Serum markers (alpha-feto protein and beta-human chorionic gonadotropin [beta-HCG]) are useful for follow-up
2) Further surgery for lymph nodes dissection may be done in some cases
3) Most testicular cancers are exquisitely radiosensitive and chemosensitive (platinum-based chemotherapy), offering many options for successful treatment in advanced, metastatic disease

Question 34

In which patients is acute urinary retention very commonly seen? How is it precipitated? How does the patient present?

Answer 34

1) Men who already have significant symptoms from benign prostatic hypertrophy
2) It is often precipitated during a cold, by the use of antihistamines and nasal drops, and by abundant fluid intake
3) The patient wants to void but cannot, and the huge distended bladder is palpable

Question 35

What is placed to help a patient with acute urinary retention? What is first line of long-term therapy? What is used for very large prostate glands (above 40g)?

Answer 35

1) An indwelling bladder catheter needs to be placed and left in for at least 3 days
2) Alpha-blockers, the most selective of which is tamsulosin
3) 5-Alpha-reductase inhibitors, like finasteride or dutasteride

Question 36

Are minimally invasive procedures for acute urinary retention popular? What is the final surgical option for benign prostatic hypertrophy?

Answer 36

1) Minimally invasive procedures using thermal ablation of prostatic tissue have not gained popularity
2) The traditional transurethral resection of the prostate (TURP), although rarely done, remains the final surgical option for benign prostatic hypertrophy

Question 37

How does posteroperative urinary retention present and why may the patient not feel the need to void? What will be palpable on physical exam? What is needed for treatment?

Answer 37

1) It is very common and sometimes it masquerades as incontinence. The patient may not feel the need to void because of post-op pain, medications, etc., but will report that every few minutes there is involuntary release of small amounts of urine
2) A huge distended bladder will be palpable, confirming that the problem is overflow incontinence from retention
3) Indwelling bladder catheter is needed

Question 38

In which patients is stress incontinence seen? How does it present? What will examination reveal?

Answer 38

1) Stress incontinence is seen in middle-age women who have had many pregnancies and vaginal deliveries
2) They leak small amounts of urine whenever intraabdominal pressure suddenly increases. This includes sneezing, laughing, getting out of a chair, or lifting a heavy object. They do not have any incontinence during the night
3) Examination will show a weak pelvic floor, with the prolapsed bladder neck outside of the “high-pressure” abdominal area

Question 39

What is treatment for stress incontinence?

Answer 39

1) Surgical repair of the pelvic floor is indicated in advanced cases with large cystoceles
2) Pelvic floor exercises may be sufficient for early cases

Question 40

How does passage of ureteral stones present? Are the stones visible on CT scan?

Answer 40

1) Passage of ureteral stones produces the classic colicky flank pain, with irradiation to the inner thigh and labia or scrotum, and sometimes nausea and vomiting
2) Most stones are visible in CT scan

Question 41

Is intervention necessary for ureteral stones? Can stones pass spontaneously? How are these cases treated?

Answer 41

1) Although there is an impressive array of fancy gadgetry available to deal with urinary stones, intervention is not always needed
2) Small (3 mm or less) stones at the ureterovesical junction have a 70% chance of passing spontaneously
3) Such cases can be handled with analgesics, plenty of fluids, and watchful waiting

Question 42

What are the chances that a 7-mm stone at the UPJ will pass on its own? What is the treatment? When can this treatment not be used?

Answer 42

1) A 7-mm stone at the UPJ only has a 5% probability of passing
2) Intervention will be required. The most common tool used is extracorporeal shock-wave lithotripsy (ESWL)
3) Sometimes ESWL cannot be used (pregnant women, bleeding diathesis, stones that are several centimeters large)

Question 43

What are alternative options to extracorporeal shock-wave lithotripsy (ESWL)? What is always universally applicable to treatment of different stones?

Answer 43

1) Other options include basket extraction, sonic probes, laser beams, and open surgery
2) Although there is specific therapy for the prevention of recurrences in defined types of stones, abundant water intake is universally applicable

Question 44

What is pneumaturia almost always caused by? What does workup start with and what will it show? What is needed later to rule out cancer? What is the treatment?

Answer 44

1) Fistulization between the bladder and the GI tract, most commonly the sigmoid colon, and most commonly from diverticulitis (second possibility is cancer of the sigmoid, and cancer of the bladder is a very distant third)
2) Workup starts with CT scan, which will show the inflammatory diverticular mass
3) Sigmoidoscopy
4) Surgical therapy is required

Question 45

What are two types of impotence?

Answer 45

Organic or psychogenic

Question 46

What is psychogenic impotence?

Answer 46

Psychogenic impotence has sudden onset, is partner- or situation-specific, does not interfere with nocturnal erections (which can be tested with a strip of perforated postage stamps), and can be effectively treated with psychotherapy only if it is done promptly

Question 47

What are examples of the sudden onset of organic impotence caused by trauma?

Answer 47

Organic impotence, if caused by trauma, will also have sudden onset, specifically related to the traumatic event (after pelvic surgery, because of nerve damage, or after trauma to the perineum, which involves arterial disruption)

Question 48

What is organic impotence because of chronic disease?

Answer 48

Organic impotence because of chronic disease (arteriosclerosis, diabetes) has very gradual onset, going from erections not lasting long enough, to being of poor quality, to not happening at all (including absence of nocturnal erections)

Question 49

What is treatment for impotence?

Answer 49

Sildenafil, tadalafil, and vardenafil have become obvious first choices of therapy in many cases, but there are many other options, including vascular surgery (well suited for those with arterial injury), suction devices (that can be used on almost everybody), and prosthetic implants (which are irreversible and fraught with complications)