Pestana Urology Flashcards
How does testicular torsion differ from acute epididymitis in terms of AGE GROUP?
Testicular torsion: young adolescent
Acute epididymitis: young men
How does testicular torsion differ from acute epididymitis in terms of SYMPTOMATOLOGY?
Testicular torsion: sudden onset of severe testicular pain, NON-tender cord, NO fever, NO pyuria, NO history of mumps
Acute epididymitis: sudden onset of severe testicular pain, TENDER cord, FEVER, PYURIA
How does testicular torsion differ from acute epididymitis in terms of PHYSICAL EXAM?
Testicular torsion: testes is “high riding” and with a “horizontal lie”
Acute epididymitis: testes is in a normal position
How does testicular torsion differ from acute epididymitis in terms of TREATMENT?
Testicular torsion: immediate surgical intervention (untwisting + orchiopexy)
Acute epididymitis: antibiotics
What should you suspect if a patient who is waiting for a stone to pass suddenly develops chills, fever spikes, and flank pain? What should you do immediately? 2
IV antibiotics + immediate decompression of the urinary tract above the obstruction via ureteral stent or percutaneous nephrostomy
Plan of care for UTI in women?
empiric antibiotics
Plan of care for UTI + pyelonephritis in women?
empiric antibiotics + UC + urologic w/u to r/o concomitant obstruction (CT or sono)
Plan of care for UTI in children or men?
empiric antibiotics + UC + urologic w/u to r/o concomitant obstruction (CT or sono)
Benefit of IVP? Limitations? 3
What two tests has replaced IVP? 3
benefit: excellent views of KUB
limitations: cannot detect early bladder allergic reactions to the dye, contraindicated in patients with limited renal function (Cr >2)
Replaced: CT (best for kidney tumors), and Sonograms (best for obstruction), Cystoscopy (best for early cancers)
What imaging modality can aid in detecting early carcinomas of the bladder?
cystoscopy
What are the symptoms of pyelonephritis?
Treatment? 3
chills, fever
N, V
flank pain
Treatment: hospitalization, IV antibiotics, and urologic w/u (CT or sono)
Acute bacterial prostatitis is commonly seen in this age group. How do they usually present?
Treatment? Precautions to take and why?
older men chills, fever dysuria, frequency diffuse back pain exquisitely tender prostate on rectal exam
Tx: IV abx
Precautions: AVOID rectal exams because continued prostatic massage can lead to SEPTIC SHOCK
common reason for a new born boy to not urinate during the first few days of life
posterior urethral valves
Diagnosis & treatment for posterior urethral valves? 3
catheterization (to empty the bladder) voiding cystourethrogram (diagnostic test) endoscopic fulguration or resection
What should you avoid doing in a male infant with obvious hypospadias and why?
avoid circumcision because the skin of the prepuce will be needed for the reconstruction
What should you do when a child presents with UTI?
urologic w/u - look for vesicoureteral reflux or congenital anomaly
What are some symptoms of vesicoureteral reflux with infection? How is it diagnosed and treated?
fever, chills, dysuria, frequency
low abdominal pain, perineal pain, flank pain
Dx: voiding cystourethrogram
Tx: long-term antibiotics until the child “grows out of the problem”
A mother brings her 6yo girl to you because “she has failed miserably to get proper toilet training.” On questioning you find out that the little girl perceives normally the sensation of having to void and voids normally and at appropriate intervals, but also happens to be wet with urine all the time. What is the most likely diagnosis and why is there a discrepancy in her symptoms?
What would you recommend?
Low-implantation of a ureter - one ureter empties into the vagina and has no sphincter; the other ureter is normally implanted and accounts for her normal voiding patterns
Recommend: corrective surgery
A 16-year-old boy goes on a beer-drinking binge for the first time in his life. Shortly thereafter he develops colicky flank pain. What is the most likely diagnosis?
Ureteropelvic junction obstruction - allows a NORMAL urinary output to flow without difficulty, but if a large diuresis occurs, the narrowed area cannot handle it, thus causing the colicky flank pain
What is the w/u of hematuria?
CT scan followed by cystoscopy
How does RCC usually present? 3
What other symptoms could be associated?
Diagnosis?
Treatment?
hematuria, flank pain, flank mass
hyperCa, erythrocytosis, and elevated liver enzymes
Dx: CT scan
Treatment: surgery
What is bladder cancer closely associated with?
smoking
How does bladder cancer usually present?
hematuria
How is bladder cancer usually diagnosed?
CT scan + cystoscopy, most likely diagnosis is bladder cancer
How is bladder cancer usually treated? 2
surgery
intravesical BCG
lifelong close follow-up due to high rate of recurrence
A 59-year-old black man has a rock-hard, discrete, 1.5-cm nodule felt in his prostate during a routine physical examination. What is the most likely diagnosis? What is the best next step in management?
Prostate cancer
Next step: transrectal needle biopsy
Treatments for localized prostate cancer?
surgical resection +/- radiation
Treatments for metastatic prostate cancer? 2
1) androgen ablation (LHRH agonist, anti-androgens like flutamide)
2) surgical (orchiectomy)
A 78-year-old man comes in for a routine medical checkup. He is asymptomatic. When a physician had seen him 5 years earlier, a PSA had been ordered, but he notices as he leaves the office this time that the study has not been requested. He asks if he should get it. What is the best next step in management?
He should NOT get the test
NB: After a certain age, most men get prostate cancer, but die of SOMETHING ELSE. As a rule, ASYMPTOMATIC PROSTATIC CANCER is not treated after the age of 75, and therefore, there is NO point in looking for it
A 25-year-old man presents with a painless, hard testicular mass. What is the most likely diagnosis? Next best step in management and treatment?
Testicular cancer - shoot to kill first, and ask questions later!
Dx: biopsy + radical orchiectomy via inguinal route
Tx: platinum based chemoRx (most are exquisitely radiosensitive and chemosensitive)
A 25-year-old man is found on a pre-employment chest x-ray to have what appears to be a pulmonary metastasis from an unknown primary tumor. Subsequent physical examination discloses a hard testicular mass, and the patient indicates that for the past 6 months he has been losing weight for no obvious reason. What is the most likely diagnosis and next best step in management?
Testicular cancer - most are exquisitely radiosensitive and chemosensitive, so get a biopsy + radical orchiectomy and then treat with platinum based chemoRx
A 60-year-old man shows up in the ER because he has not been able to void for the past 12 hours. PE shows a palpable bladder with a big, boggy prostate without nodules. Because of a cold, 2 days ago he began taking antihistamines, using “nasal drops,” and drinking plenty of fluids. What is the most likely diagnosis and next best step in ACUTE management?
Acute urinary retention with underlying BPH
Place an indwelling catheter for at least 3 days
A 60-year-old man shows up in the ER because he has not been able to void for the past 12 hours. PE shows a palpable bladder with a big, boggy prostate without nodules. Because of a cold, 2 days ago he began taking antihistamines, using “nasal drops,” and drinking plenty of fluids. What is the most likely diagnosis and next best step in LONG-TERM management? 3
Diagnosis: Acute urinary retention with underlying BPH
1) alpha blockers (tamsulosin, doxazosin, terazosin)
2) 5a-reductase inhibitors (finasteride, dutasteride) for very large glands
3) TURP (rarely done)
On the second postoperative day after surgery for repair of bilateral inguinal hernias, the patient reports that he “cannot hold his urine.” Further questioning reveals that every few minutes he urinates a few milliliters of urine. On physical examination there is a large palpable mass arising from the pelvis and reaching almost to the umbilicus. What is the most likely diagnosis and how should this be treated?
Acute urinary retention with overflow incontinence
Tx: indwelling catheter
A 72yo M is having relatively mild pain that began 6 hours ago. Q scan shows a 3-mm ureteral stone just proximal to the ureterovesical junction. What is the best next step in management?
for a small stone that is almost at the bladder with minimal symptoms, treat with
- time
- pain medication (morphine, NSAIDs), and plenty of fluids, and he will probably pass it
A 54-year-old woman has a severe ureteral colic CT scan shows a 7-mm ureteral stone at the ureteropelvic junction. What is the best next step in management?
A 3-mm stone has a 70% chance of passing, but a 7-mm stone only has a 5% probability of doing so.
Tx: extracorporeal shock-wave lithotripsy (ESWL)
3 contraindications to ESWL
- pregnancy
- bleeding diathesis
- stones that are several centimeters big (treat with PCNL instead)
What is pneumaturia?
What is it commonly caused by?
passage of gas or “air” in urine; usually caused by diverticulitis
A 72-year-old man consults you with a history that for the past several days he has noticed that bubbles of air come out along with the urine when he urinates. What is diagnosis and the best next steps in management? 3
Dx: pneumaturia
management:
CT scan (shows diverticular mass)
sigmoidoscopy (to r/o cancer)
surgical therapy
2 general causes of impotence
psychogenic vs organic (secondary to trauma or chronic disease)
32yo M with sudden onset of impotence. One month ago he was unexpectedly unable to perform with his gf after an evening of heavy drinking. Ever since then he has not been able to achieve an erection when attempting to have intercourse with his gf, though he still gets nocturnal erections and can masturbate normally. What is the most likely diagnosis and next step in management?
Psychogenic impotence:
- sudden onset
- partner-specific
- does not interfere with nocturnal erections
Tx: psychotherapy
Ever since he had a motorcycle accident where he crushed his perineum, a young man has been impotent. What is the most likely diagnosis and treatment?
Organic impotence due to trauma, likely vascular injury
- sudden onset
Tx: vascular reconstruction
Ever since he had an abdominoperineal resection for cancer of the rectum, a 52-year-old man has been impotent. What is the most likely diagnosis and treatment?
Organic impotence due to surgical trauma, likely nerve injury
- sudden onset
Tx: suction or prosthetic devices
A 66-year-old diabetic man with generalized arteriosclerotic occlusive disease notices gradual loss of erectile function. At first he could get erections, but they did not last long; later the quality of the erection was poor; and eventually he developed complete impotence. He does not get nocturnal erections. What is the most likely diagnosis?
Organic impotence (not related to trauma) - gradual decline of erections
Rx that “fils” the penis:
- sildenafil,
- tadalafil, and
- vardenafil
