SASP 2022 Flashcards
A 46-year-old man with a high velocity GSW to the right lower abdomen has a normal urinalysis. During laparotomy, a small bowel perforation and right iliac vein injury are repaired. Intraoperative IVP reveals prompt bilateral excretion of contrast with no extravasation. The next step is:
A. no further evaluation.
B.
ureteral inspection.
C.
I.V. fluorescein.
D.
bladder filling with methylene blue.
E.
retrograde ureteropyelography.
The frequency of ureteral injuries from penetrating trauma is low. Given this location, however, there is a high likelihood of ureteral injury, regardless of the appearance of the IVP. These injuries may be difficult to detect because the IVP is either normal or indeterminate in approximately 70% and hematuria may be absent in up to 45%. Retrograde ureteropyelography or injection of dyes (i.e., I.V. fluorescein) may miss such injuries because the blast injury often results in delayed sloughing. Without gross hematuria, a bladder injury is unlikely, and therefore intravesical methylene blue is unnecessary. A high index of suspicion is necessary for diagnosis of a ureteral injury and the most accurate method is ureteral inspection. Given the vein repair, the area of interest is exposed, and inspection should not be difficult.
A 58-year-old man has frequency and nocturia, an AUA Symptom Score of 22, peak urinary flow rate of 8 mL/sec, and PVR of 200 mL. His prostate is 70 grams with a prominent median lobe. Sitting systolic blood pressure is 140 mmHg. An orthostatic blood pressure change of 25 mmHg is not associated with postural symptoms. He is concerned about developing ejaculatory dysfunction. The best treatment is:
A.
finasteride.
B.
alfuzosin.
C.
TUIP.
D.
transurethral vaporization of the prostate.
Orthostatic hypotension is not a contraindication for alpha-blockers providing the blood pressure change is not associated with postural symptoms. Alpha-blockers, such as alfuzosin, are the first-line treatment for men with BPH/LUTS and their effectiveness is independent of prostate size. Alfuzosin has the lowest rate of ejaculatory dysfunction (< 1%) of all the medicines in this class. Finasteride will decrease semen volume and will take several months to take effect. While the rate of retrograde ejaculation with TUIP is low, it still has an approximately 11% rate of ejaculatory dysfunction. Transurethral vaporization of the prostate has a high rate of retrograde ejaculation, similar to TURP. If this man fails to improve on alfuzosin, UroLift® might be an option. However, while UroLift® does not cause retrograde ejaculation, it is not currently recommended for patients with enlarged median lobes. Rezum® is an option for this patient should he fail medical therapy or choose not to undergo a trial of medical therapy.
Two months following closure of a traumatic bladder rupture associated with a pelvic fracture, a 20-year-old man is now voiding but has persistent leakage through his prior suprapubic tube site. The next step is:
A.
CT urogram.
B.
pelvic MRI scan.
C.
fistulogram.
D.
cystourethroscopy.
E.
UDS.
When faced with a patient with a persistent urinary fistula, the acronym FETID will aid the physician in determining its etiology and management plans: F- Foreign Body, E- Epithelization of the fistula tract, T- Tumor or chronic trauma causing persistence, I- Infection, or chronic inflammation arising from inflammatory bowel disease, XRT, etc., D- Distal obstruction. In this young patient with a history of persistent fistula following closure of a bladder rupture after a pelvic fracture, persistent drainage from a suprapubic tube site is most likely from either a foreign body within the bladder (i.e., bony spicule or bladder calculi formed as a nidus from the prior indwelling suprapubic tube) or bladder outlet obstruction arising from either a bladder neck contracture or urethral stricture. The single best diagnostic study is cystourethroscopy. Pressure flow UDS could demonstrate findings consistent with high-pressure voiding and outlet obstruction. But the source of the obstruction, which is likely a urethral stricture or a bladder neck contracture, would not be able to be determined by this test and this test does not rule-out the possibility of a foreign body within the bladder. A CT scan may allow one to visualize either a foreign body (bone or hardware) or bladder calculi but would not be able to assess the urinary outlet. Similarly, a fistulogram or pelvic MRI scan are unlikely to yield adequate diagnostic information in this situation to result in definitive operative plans.
A 69-year-old woman with hypertension and palpitations has elevated plasma free metanephrines. CT scan is shown. In addition to blood pressure control, the next step is:
View Images
A.
gallium-68 dotatate PET scan.
B.
adrenal venous sampling.
C.
iodine-131-MIBG.
D.
mitotane.
E.
cisplatin and etoposide.
The patient has a clinical presentation, radiographic features, and laboratory studies consistent with a paraganglioma. Initial management should involve alpha-blockade to establish blood pressure control. Staging evaluation for metastases in this setting is recommended, with gallium-68 dotatate PET having emerged as the preferred imaging modality. Dotatate has a high affinity for the somatostatin surface receptor, which is expressed by paragangliomas, and thereby facilitates detection of metastatic disease which may in turn impact management. Iodine-131-MIBG represents a form of systemic therapy that may be utilized for patients with metastatic disease or locally unresectable tumors in whom a prior MIBG scan has been obtained and is positive. Meanwhile, adrenal vein sampling has been reported to have a sensitivity of 95% and a specificity of 100% for detecting lateralized autonomous aldosterone secretion but would not be indicated in the evaluation of a patient with a likely retroperitoneal paraganglioma. Both cisplatin and etoposide as well as mitotane are systemic therapy options for patients with metastatic adrenocortical carcinoma (with cisplatin/etoposide preferred) but would not be indicated here in a functional paraganglioma and without documented metastatic disease.
A five-year-old boy has day and night wetting, constipation, and fecal soiling. Physical examination is normal except for a high-arched right foot. UDS shows detrusor overactivity and normal sphincter function. PVR is 5 mL. The next step is:
A.
CIC.
B.
timed voiding schedule.
C.
spinal MRI scan.
D.
antimuscarinics.
E.
bowel program.
The patient has the urologic finding of incontinence combined with fecal soiling and a high-arched foot abnormality. A foot abnormality, such as a high-arched foot or abnormal gait, can signify a tethered cord. A tethered cord due to occult spinal dysraphism needs to be ruled out as the cause of his incontinence. Tethered cord syndrome is a stretch-induced functional disorder of the spinal cord with the most caudal part of the cord anchored by inelastic structures. Specific treatment of his detrusor overactivity with timed voids, medication, and/or treatment of constipation is appropriate after a neurologic cause is excluded. CIC would not be needed without evidence of urinary retention.
A 70-year-old woman has intermittent large volume urinary incontinence. Her medical history is significant for a hysterectomy 20 years ago. Urinalysis is normal and PVR is 40 mL. During the CMG, there is no incontinence demonstrated during filling and stress maneuvers, and the end fill pressure is 6 cm H2O at 300 mL. The most likely cause of her incontinence is:
A.
overflow.
B.
detrusor overactivity.
C.
decreased detrusor compliance.
D.
intrinsic sphincter deficiency.
E.
VVF.
This patient likely has urgency urinary incontinence secondary to detrusor overactivity, as indicated by the random nature of the incontinence. UDS will fail to demonstrate involuntary bladder contractions in approximately 50% of patients with clinical urgency urinary incontinence. SUI occurs during increased abdominal pressure, and she is not describing leakage during these types of events such as coughing, lifting, and exercise. In addition, SUI, including intrinsic sphincter deficiency, is not demonstrated on UDS since urinary leakage did not occur during Valsalva maneuvers. The characteristics of the incontinence are not consistent with a VVF as the urinary leakage is not continuous. She has a normal detrusor pressure at the end of filling, confirming normal compliance (300 mL/6 cm H2O=50 mL/cm H2O). Her PVR of 40 mL demonstrates that she is not in urinary retention and thus rules out overflow incontinence.
The manifestation of the VHL syndrome that tends to cluster within a subset of affected families is:
A.
RCC.
B.
pheochromocytoma.
C.
retinal angioma.
D.
cerebellar hemangioblastoma.
E.
epididymal papillary cystadenoma.
Penetrance for all of the manifestations of VHL is incomplete. In particular, pheochromocytomas have been found to cluster only in certain families with VHL, primarily those with a missense mutation of the VHL gene. A careful family history and thorough review of preoperative CT scans for potential associated tumors are important in all patients with familial RCC. Indeed, pheochromocytomas are a critical entity to recognize prior to any surgical intervention, given the potential perioperative morbidity of an unrecognized pheochromocytoma. The other listed manifestations of VHL are not as well-characterized by familial clustering.
A 37-year-old woman with a continent cutaneous urinary diversion becomes febrile and develops mental status changes and marked hepatic dysfunction. Previously, her hepatic function had been normal. In addition to prompt urinary drainage and systemic antibiotics, the next step is:
A.
lactulose.
B.
Vitamin B12.
C.
sodium bicarbonate.
D.
nicotinic acid.
E.
thiamine and folic acid.
Urinary ammonium excreted by the kidneys is reabsorbed by the intestinal segment and then returned to the liver via the portal circulation. The liver metabolizes ammonium to urea via the ornithine cycle. The liver usually adapts to the excess ammonia in the portal circulation without difficulty and rapidly metabolizes the urea. In the setting of hepatic dysfunction, the hepatic reserve for ammonium metabolism may be exceeded, resulting in the complication of an ammoniagenic coma. The syndrome, however, also has been described in patients with normal hepatic function. Systemic bacteremia, with endotoxin production, inhibits hepatic function and may precipitate this clinical entity. UTIs with urea-splitting organisms may also overload the ability of the liver to clear the ammonia. If this syndrome occurs in a patient suspected of having near-normal hepatic function, systemic bacteremia or urinary obstruction should be suspected. Prompt urinary drainage with treatment of the offending urinary pathogens along with systemic antibiotics and the administration of oral neomycin or lactulose to reduce the absorption of ammonia in the gastrointestinal tract are the key components to patient management. There is no indication for the use of Vitamin B12, sodium bicarbonate, nicotinic acid, thiamine, and folic acid in this clinical setting.
A 67-year-old man has an IPSS of 25 and a bother score of 5. He has no history of urinary retention, infections or stones, and has normal renal function. DRE reveals a 25 gram benign prostate. The next step is:
A.
observation.
B.
alpha-blocker.
C.
5-alpha-reductase inhibitor.
D.
alpha-blocker and 5-alpha-reductase inhibitor.
E.
UroLift®.
This patient has a high IPSS with a significant bother score, therefore watchful waiting is not appropriate, and he should be offered intervention. A VA study of 1229 patients randomized to placebo, alpha-blocker therapy, finasteride, or combination therapy with alpha-blockers plus finasteride showed the superiority of alpha-blocker therapy alone in improvement of symptoms and peak flow rate. Other than an additional reduction in prostate volume, combination therapy with finasteride did not provide significantly more symptom relief. Combination therapy may be beneficial in a man with an enlarged prostate; however, there is no indication that the prostate is enlarged in this individual, and therefore, the initial cost and potential adverse effects of combination therapy are not justified in this untreated patient. Medical therapy of prostatic symptoms has shown a reduction in BPH progression with combination therapy, though this question focuses on symptomatic relief in a patient without significant prostatic enlargement, which would be best achieved by alpha-blockade alone. This patient has no absolute indication for surgical therapy such as UroLift® although it may be considered if the patient chooses not to undergo medical therapy.
During laparoscopic left radical nephrectomy, minimal placement of clips on the primary branches of the main renal vein is most important to facilitate:
A.
lymphadenectomy.
B.
en bloc excision with negative margins.
C.
adrenalectomy.
D.
application of the endovascular stapler onto the main renal vein.
E.
dissection and occlusion of the main renal artery(ies).
EXPLANATION
Excessive placement of clips when managing the gonadal, adrenal, or lumbar branches of the left renal vein can severely restrict the working space available for safe placement of the endovascular stapler later in the case when the main renal vein is to be addressed. Application of the stapler across a clip can lead to stapler misfire and subsequent hemorrhage and should therefore be avoided. Use of clips is not likely to significantly impact the ability to perform the lymphadenectomy, adrenalectomy, the ability to achieve negative margins, or the ability to control the renal artery.
A 48-year-old man undergoes partial nephrectomy for a 3 cm renal mass. His flank drain is removed on the third postoperative day. Seven days later, he has clear fluid dripping from the flank drain site. He is otherwise asymptomatic. CT scan demonstrates a 5 cm by 10 cm fluid collection adjacent to the kidney with extravasation of contrast from the collecting system. The next step is:
A.
observation.
B.
urethral catheter.
C.
percutaneous drainage of urinoma.
D.
PCNT.
E.
ureteral stent.
Urine leak following partial nephrectomy occurs in up to 15% of cases. If a postoperative drain is left in situ, spontaneous closure of the urinary leak usually occurs within two to four weeks. In the case of an unrecognized or delayed urinary leak, the presence of an adjacent urinoma may prevent fistula closure and predispose the patient to infection/abscess formation. Percutaneous drainage of the urinoma is the preferred method used to control a delayed pyelocutaneous fistula. If the leak does not heal with drainage of the urinoma, consideration should be given to the possibility of either ureteral/bladder obstruction or bladder dysfunction as a cause of the persistent fistula. In these situations, a cystoscopy with a retrograde pyelogram followed by ureteral stent and urethral catheter placement should be pursued. The concomitant urethral catheter is used to aid healing by preventing high-pressure reflux up the ureteral stent and/or to treat bladder outlet obstruction or voiding dysfunction as an etiology for the persistent urinary fistula or urinary leak. PCNT would be considered if a ureteral stent could not be placed.
A 23-year-old addict is treated with I.V. antibiotics and percutaneous drainage for a renal abscess. Forty-eight hours after admission, he continues to have high fever and is found injecting himself with heroin. He physically assaults a security guard and now demands to be discharged against medical advice. The next step is:
A.
discharge from the hospital on oral antibiotic therapy.
B.
allow discharge against medical advice.
C.
sedation, physical restraint, and continue treatment.
D.
transfer to a chemical dependency unit.
E.
notify legal authorities and continue treatment
The continued use of I.V. street drugs while under treatment directly affects the likelihood of medical success. His abusive and illegal behavior could stem from his underlying social pathology or could indicate alterations in mental capacity from additional infected cerebral sites. The use of street drugs coupled with an assault on the hospital staff should result in turning this patient over to legal authorities, who can mandate and supervise additional diagnosis and treatment. This will provide security for the treating staff and protection of the patient from his own actions.
A 72-year-old man is noted to have a large bladder on a CT scan performed for colonic diverticular disease. He has no LUTS. His prostate is 30 grams and benign. PVR is 350 mL. Urinalysis is negative. The next step is:
A.
observation.
B.
alpha-blocker.
C.
5-alpha-reductase inhibitor.
D.
5-alpha-reductase inhibitor and an alpha-blocker.
E.
Rezum®.
PVR measurement has significant intra-individual variability and does not correlate well with other signs or symptoms of lower urinary tract dysfunction. The VA Cooperative Study Group (which evaluated men with bothersome LUTS secondary to bladder outlet obstruction) demonstrated that PVR does not predict the outcome of surgery and the majority of men with large residual urine volume did not require surgery during the duration of the trial. Men with significant PVRs should be monitored more closely if they elect no therapy. This man would be considered to have low risk chronic urinary retention (PVR > 300 mL) because he has no signs or symptoms of upper tract deterioration or UTIs. Medical therapy for BPH is indicated in men who have bothersome symptoms that negatively affect their quality of life. First-line medical therapies include alpha-blockers, 5-alpha-reductase inhibitors, or a combination of the two. Minimally invasive or surgical therapy, such as Rezum®, is not indicated in men without bothersome symptoms.
One hundred patients undergo abdominal imaging for staging prior to RPLND. Retroperitoneal metastatic disease is confirmed in 50 patients at surgery. With imaging, there were 20 false positives and 10 false negatives. The sensitivity of the imaging is:
A.
50%.
B.
60%.
C.
67%.
D.
75%.
E.
80%.
A test with high sensitivity (good for screening) reliably finds a disease when it is present and avoids false negatives. A test with high specificity (good for confirmation) reliably excludes a disease when it is absent and avoids false positives. Positive predictive value is the probability a person has disease if test result is positive. Negative predictive value is the probability a person does not have the disease if the test result is negative. The test result can be true positive (TP), true negative (TN), false positive (FP), or false negative (FN). The number with disease = TP + FN = 50. FN = 10; therefore, TP = 40. The number without disease = FP + TN = 50. FP = 20; therefore, TN = 30. The prevalence of disease in this study is 50%. Sensitivity = TP/(TP + FN) = 40/(40 + 10) = 80%. Specificity = TN/(FP + TN) = 30/(20 + 30) = 60%. Positive predictive value = TP/(TP + FP) = 40/(40 + 20) = 67%. Negative predictive value = TN/(FN + TN) = 30/(10 + 30) = 75%.
A 52-year-old man with erectile dysfunction undergoes videourodynamics for voiding dysfunction. A videourodynamic image, taken early in filling (at the point indicated by dotted line in the UDS tracing), is shown. The videourodynamics suggests a diagnosis of:
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A.
bladder neck dyssynergia.
B.
cervical spinal stenosis.
C.
Parkinson’s disease.
D.
multiple system atrophy (Shy-Drager Syndrome).
E.
multiple sclerosis (MS).
The cystogram demonstrates an open bladder neck at rest. The UDS tracing shows that there was no detrusor activity at the instant the image was obtained. An open bladder neck at rest in a male is highly suggestive of multiple system atrophy (MSA-formerly known as Shy Drager Syndrome) in the absence of prior prostate surgery. Although other neurological diseases may result in an open bladder neck at rest, none of these are listed except MSA. Erectile dysfunction is often found in MSA, and this finding in concert with the open bladder neck at rest distinguishes this condition from Parkinson’s disease (PD) which is often clinically similar in many other respects. Other symptoms of MSA may include other autonomic dysfunctions. Bladder neck dyssynergy would have a closed bladder neck with filling. Cervical spinal stenosis and MS would not typically have an open bladder neck at rest. A further distinction between PD and MSA is that bladder symptoms occur earlier in the course of MSA compared to PD patients.
A 28-year-old man has acute scrotal pain. Ultrasound reveals testicular torsion. The consulting urologist is unavailable and asks that pain medication be withheld until surgical consent can be obtained in one hour. The ER physician should:
A.
withhold pain medication.
B.
administer appropriate analgesics.
C.
transfer to nearest hospital.
D.
obtain consent for surgery.
E.
give pain medication and obtain consent from a relative.
The patient should receive appropriate analgesics, and surgical consent should be obtained only by a member of the surgical team. This surgeon has the common misconception that informed consent is somehow invalidated by the presence of specific medications. Patients who present for surgery may have taken a variety of medications, many of which can have effects on mental function. The issue is not whether the patient has been premedicated, but whether premedication has impaired the patient’s ability to participate in the informed consent process. While it is appropriate to give pain medication, it is not appropriate to obtain consent from another party if the patient still has decision-making capacity. The ethical issues involved in this case include assessment of the patient’s capacity to make decisions and whether the patient is deliberately or otherwise being coerced into consenting for surgery. The patient’s capacity to provide consent is determined not by what recent medications have been given but by whether the patient understands the need for treatment, can listen to and understand treatment options and risks, and can then express a choice regarding their care. Respect for patient autonomy requires that we promote a patient’s ability to make an “unencumbered” choice. Severe pain, by impairing a patient’s ability to listen and understand, is an encumbrance to the informed consent process. Further, withholding pain medication for the purpose of obtaining consent might be coercive.
A 47-year-old woman has SUI and a urethral diverticulum. UDS demonstrates a Valsalva LPP of 50 cm H2O. The best treatment is urethral diverticulectomy and:
A.
staged urethral bulking if SUI persists.
B.
Martius fat pad.
C.
pubovaginal sling.
D.
midurethral sling.
E.
Burch colposuspension.
A concomitant incontinence procedure should be considered given her SUI symptoms and demonstration of loss of urine with Valsalva on UDS. A pubovaginal fascial sling would treat the SUI without increased risk of urethral erosion. Concomitant placement of a synthetic midurethral sling should be avoided because of the potential risk of infection and erosion into the urinary tract and according to AUA Guidelines is not recommended at the time of urethral diverticulectomy. A Martius fat pad will not treat the incontinence. Her intrinsic sphincter deficiency, as suggested by the Valsalva LPP, is better treated with a sling rather than a Burch procedure
A 55-year-old man with erectile dysfunction has a 60 degree ventral curvature of his penis of 18 months duration. On duplex Doppler ultrasound, his peak systolic velocities are 40 cm/sec; end-diastolic velocities are 10 cm/sec bilaterally. The next step is:
A.
intralesional verapamil.
B.
shockwave therapy.
C.
penile plication.
D.
plaque incision and grafting.
E.
placement of a penile implant.
The patient has stable curvature precluding him from having sexual intercourse. His hemodynamic assessment indicates normal arterial inflows (peak systolic velocities > 30 cm/sec). However, there is evidence of veno-occlusive dysfunction (end diastolic velocities > 5 cm/sec). Intralesional injection therapy has not been shown to render men with this severity of curvature functional. Shock wave therapy is only indicated for pain related to Peyronie’s disease. Plication surgery will result in significant loss of penile length because of the degree of curvature and will not address the erectile dysfunction due to venous leakage. According to the AUA Guidelines on Peyronie’s disease, clinicians may offer plaque incision or excision and/or grafting to patients with deformities whose rigidity is adequate for coitus (with or without pharmacotherapy and/or vacuum device therapy) to improve penile curvature. In men with this preoperative hemodynamic profile and erectile dysfunction, the procedure will not improve his erectile dysfunction and will render him incapable of having intercourse even with a straight penis. Penile implant surgery is indicated in men with this degree of curvature and erectile function.
An asymptomatic five-year-old boy has gross hematuria two hours after wrestling with his younger brother. Physical examination is normal. The next step is:
A.
observation.
B.
serial examinations and hematocrit determination.
C.
ultrasound of bladder and kidneys.
D.
CT scan.
E.
cystoscopy.
It is recognized that underlying genitourinary malformations or other pathologies are at least three-fold more common in pediatric patients relative to adults undergoing evaluation for trauma. This is a classic case for raising the concern of an underlying abnormality since the gross hematuria seems out of proportion with the low severity of the trauma. The underlying problems may include hydronephrosis, multicystic kidney, Wilms’ tumor, and various renal fusion anomalies. Therefore, it is appropriate to image with ultrasound to look for such potentially significant problems. A patient should not be considered for admission with serial examinations and hematocrit determination unless there is a documented substantial renal injury. Cystoscopy is not indicated in the initial evaluation of gross hematuria in children. CT scan would only be indicated if there is significant injury or abnormality on ultrasound or if the mechanism of injury was more concerning.
A 32-year-old woman with severe pyelonephritis is receiving ampicillin combined with a single daily dose of gentamicin, 7 mg/kg. After 36 hours, she remains febrile and has persistent flank pain. Following the second dose, a trough serum gentamicin level is 12 mcg/mL (normal is 5-10 mcg/mL). The next step is:
A.
continue current gentamicin regimen.
B.
continue gentamicin and start n-acetylcysteine.
C.
decrease gentamicin dose.
D.
decrease gentamicin frequency.
E.
discontinue gentamicin and start aztreonam.
When combined with trimethoprim/sulfamethoxazole (TMP-SMX) or ampicillin, aminoglycosides are the first drugs of choice for febrile UTIs. Their nephrotoxicity and ototoxicity are well-recognized; hence, careful monitoring of patients for renal and auditory impairment as well as serum levels is indicated. Once-daily aminoglycoside regimens have been instituted to maximize bacterial killing by optimizing the peak concentration to minimal inhibitory concentration ratio and reduce the potential for toxicity. Administering an aminoglycoside as a single daily dose can take advantage not only of its concentration-dependent killing ability but also of two other important characteristics: time-dependent toxicity and a more prolonged post-antimicrobial effect. The regimen consists of 5-7 mg/kg daily dose of gentamicin or 5-7 mg/kg dose of tobramycin. Subsequent interval adjustments are made by obtaining a single concentration in serum and a nomogram designed for monitoring of once-daily therapy. Antimicrobial doses are given at the interval determined by the drug concentration of a sample obtained after the start of the initial infusion. This regimen is clinically effective, reduces the incidence of nephrotoxicity, and provides a cost-effective method for administering aminoglycosides by reducing ancillary service times and serum aminoglycoside determinations. In this case, the serum level of gentamicin is high and requires adjustment. Changing the dosing interval from every 24 hours to every 36 hours is indicated. Decreasing the dose may lead to the same reduction in levels but with a reduction in effectiveness. Although the patient continues to have symptoms, this is common during the initial course of pyelonephritis and is not an indication at 48 hours to change antibiotic regimen. There are no indications to start aztreonam or n-acetylcysteine.
A seven-year-old boy has had multiple repairs for penoscrotal hypospadias. He has recurrent lower UTIs and postvoid dribbling. Renal ultrasound is normal. Pelvic ultrasound is shown. The most likely diagnosis is:
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A.
cecoureterocele.
B.
ectopic ureter.
C.
Cowper’s duct cyst.
D.
prostatic utricle.
E.
bladder diverticulum.
In boys with proximal hypospadias, the prostatic utricle is often enlarged. In a female, this would represent the distal one-third of the vagina. The utricle is of urogenital sinus origin. While an ectopic ureter or bladder diverticulum could have a similar appearance on ultrasound, they generally are not midline in location. Ectopic ureter or bladder diverticulum are not commonly seen with hypospadias. A cecoureterocele would have a bladder deformity in addition to a suburethral extension. A Cowper’s duct cyst, also known as a syringocele, should be confined to the bulbous or prostatic urethra where Cowper’s ducts drain.
A 65-year-old man uses 20 mg of tadalafil as needed for erectile dysfunction. His primary care provider would like to initiate doxazosin for hypertension. The next step is:
A.
continue tadalafil 20 mg as needed.
B.
decrease tadalafil to 10 mg as needed.
C.
start tadalafil 5 mg daily.
D.
stop tadalafil.
E.
switch to intracorporal alprostadil.
Concomitant use of alpha-blockers and PDE-5 inhibitors can cause hypotension. When tadalafil is coadministered with an alpha-blocker, patients should be stable on alpha-blocker therapy prior to initiating treatment with tadalafil, and tadalafil should be initiated at the lowest recommended dose. Conversely, when starting an alpha-blocker, the lowest dose of either agent should be used, and they should not be taken at the same time. There is no need to stop tadalafil in this patient or switch to intracorporal injections if he has been successful on oral therapy. Of all the choices, decreasing to the lowest effective dose of tadalafil (10 mg for use as needed or 2.5 mg/day for once daily use) would be recommended for this man.
A 58-year-old man has fever, chills, and elevated alanine aminotransferase and aspartate aminotransferase two days after receiving his fourth dose of intravesical BCG for bladder cancer. Urinalysis was notable only for occasional RBCs. In addition to supportive care, isoniazid, and rifampin, the next step is:
A.
pyrazinamide.
B.
cycloserine.
C.
corticosteroids.
D.
cyclosporine.
E.
gentamicin.
Disseminated BCG (grade 3 serious complications) presents with systemic signs and symptoms, some of which are due to acute inflammatory response to the bacillus. Thus, systemic steroids are recommended in addition to the standard drug regimen to which a BCG-associated infection usually responds. BCG, an attenuated strain of Mycobacterium bovis, is poorly controlled by pyrazinamide due to uniform resistance. Cycloserine often causes severe psychiatric symptoms and is strongly discouraged. The immunosuppressant cyclosporine has no role in the management of disseminated BCG. There is no clear evidence of a bacterial infection, so the use of gentamicin is not indicated.
