SASP 2nd Round Flashcards
A 72-year-old woman has had six symptomatic UTIs over the past year. These infections return shortly after antibiotic courses are concluded, and cultures have demonstrated significant colony counts of E. coli. Renal ultrasound is normal. The next step is:
A: ciprofloxacin prophylaxis. B: nitrofurantoin prophylaxis. C: oral low dose estrogen. D: intravaginal estrogen. E: lactobacillus.
D: “intravaginal estrogen.” is correct.
The efficacy of estrogen for the prevention of UTI in post-menopausal women has been demonstrated in several studies. There appears to be a higher effectiveness rate in topically applied estrogen in the vagina with an improvement in lactobacillus concentrations, decreased vaginal pH and a decrease in UTI episodes from 5.9 to 0.5 episodes per year. Antimicrobial prophylaxis may be used at low dose if topical estrogen fails. Lactobacillus probiotics, while effective in an investigational setting, have not been subject to the scrutiny of controlled trials.
Question 17 of 150
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 urodynamic tracing), is shown (open bladder neck during filling phase). The videourodynamics suggests a diagnosis of:
A: bladder neck dyssynergia. B: cervical spinal stenosis. C: Parkinson's disease. D: Multiple System Atrophy (Shy-Drager). E: multiple sclerosis.
D: “Multiple System Atrophy (Shy-Drager).” was the correct answer.
The cystogram demonstrates an open bladder neck at rest. The urodynamics 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) 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 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.
Question 18 of 150
When compared to age-matched controls, men treated with etoposide and platinum-based chemotherapy for NSGCT are at increased long term risk of:
A: systemic infection. B: pulmonary fibrosis. C: cardiovascular disease. D: ototoxicity. E: autoimmune disease.
C: “cardiovascular disease.” was the correct answer.
The long term toxicity of bleomycin containing chemotherapy regimens includes pulmonary fibrosis however etoposide and platinum does not appear to be associated with this toxicity. There is no chronic increase in risk of systemic infection despite a short term risk of neutropenic sepsis during therapy. Several large scale epidemiologic studies have recently concluded that men treated with either radiation therapy or systemic platinum containing chemotherapy are at significantly increased risk of developing both fatal cardiovascular events as well as secondary malignancy after extended follow-up.
Question 27 of 150
A 68-year-old man undergoes a partial penectomy for a 4 cm squamous cell carcinoma with lymphovascular invasion and involvement of the subepithelial connective tissue. Physical exam reveals a 1.5 cm fixed, right inguinal mass. CT scans of the abdomen and pelvis are normal. His pathologic tumor stage (p) and clinical lymph node stage (c) are:
A: pTa cN1. B: pT1a cN1. C: pT1b cN2. D: pT1b cN3. E: pT2 cN3.
D: “pT1b cN3.” was the correct answer.
The 2010 AJCC staging for penile cancer made several significant changes. This patient has a pT1 tumor because of his subepithelial connective tissue involvement. Those patients with low grade tumors and without lymphovascular invasion are pT1a. This patient, however, has lymphovascular invasion and as a result is a pT1b. Patients with lymphovascular invasion are in fact at higher risk for metastatic disease. For the first time, nodal staging is divided into both clinical and pathologic staging schemes. With a palpable, fixed nodal mass, regardless of the size or unilateral/bilateral involvement, the clinical lymph node status is cN3.
Question 31 of 150
A 65-year-old man undergoes radical cystectomy and orthotopic neobladder urinary diversion for pT2b urothelial carcinoma of the bladder. A key maneuver for maintaining continence is:
A: maximizing the length of the neobladder.
B: minimizing the length of the urethra to prevent kinking.
C: placing an intraoperative urethral sling.
D: forming a funnel-shaped reservoir.
E: performing bilateral nerve-sparing surgery.
E: “performing bilateral nerve-sparing surgery.” was the correct answer.
Factors that may increase leakage in patients with an orthotopic neobladder include: shortened functional urethral length, non-nerve sparing, decreased membranous urethral sensation, and increased time after diversion (as patients age.) Formulation of a funnel-shaped reservoir in fact increases kinking and increases the likelihood of failure of spontaneous voiding. Nerve-sparing may in fact aid in the functionality of the neobladder although exact mechanism is unknown. No data exists for a placement of urethral sling being helpful in maintaining continence and may promote hypercontinence.
Question 32 of 150
A 32-year-old man has recurrent calcium oxalate stone formation. Despite an oxalate restricted diet, his urinary oxalate is high. The next step is:
A: pyridoxine. B: hydrochlorothiazide. C: allopurinol. D: alpha-mercaptoproprionyl glycine. E: Vitamin B12.
A: “pyridoxine.” was the correct answer.
Pyridoxine reduces oxalate production in up to 50% of patients with mild hyperoxaluria. Pyridoxine, a component of Vitamin B6, is a co-factor for alanine:glyoxylate aminotransferase (AGT), which converts glyoxylate to glycine. In doing so, less glyoxylate is available as a substrate for LDH which leads to a decrease in endogenous oxalate production. The other agents will have no impact on urinary oxalate.
Question 63 of 150
A five-year-old boy with a history of PUV ablation is incontinent day and night. Renal ultrasound shows normal kidneys bilaterally. VCUG shows a mildly trabeculated bladder without VUR and a patent urethra. PVR is 10 ml. He has normal daily bowel movements. The urinalysis is normal, and he has not had any UTIs. The next step is:
A: timed voiding. B: nocturnal bladder drainage. C: urodynamic study. D: oxybutynin. E: desmopressin.
A: “timed voiding.” is correct.
Voiding dysfunction and incontinence are common in boys with history of PUV. Over 80% will struggle with incontinence at age five. Nocturnal bladder drainage is usually indicated in the presence of high urinary output which can occur in boys with a history of PUV secondary to a concentrating defect. In such patients, significant hydroureteronephrosis is expected, which this patient does not have. Since he is not retaining urine after voiding, urodynamic test will likely demonstrate a pattern of bladder overactivity. However, it is appropriate to try conservative measures such as timed voiding prior to proceeding with more invasive testing such as urodynamics. Oxybutynin must be used with caution since a possible underlying myogenic dysfunction could lead to outright urinary retention. Desmopressin will not affect bladder dysfunction, which is the primary etiology of incontinence in boys with PUV.
Question 66 of 150
A five-year-old girl is evaluated for a febrile UTI. She has daytime urgency and rare wetting. She is dry at night. Physical examination is normal. A renal US is normal and a VCUG shows bilateral grade 2 VUR. Spina bifida occulta at L5 is noted on the scout film. The next steps are prophylactic antibiotics and:
A: spinal MRI scan. B: urodynamics. C: timed voiding. D: oxybutynin. E: endoscopic correction of reflux.
C: “timed voiding.” was the correct answer.
Spina bifida occulta is often identified on spine films. In a child with a normal physical examination the chance of a spinal cord abnormality is very small. These children should be treated the same as other children with urgency and daytime wetting. The initial management is timed voiding and maintenance of a voiding diary. Since it is very likely that this VUR will resolve with behavioral modification surgical management including endoscopic treatment is not indicated. Urodynamics would be reserved for those children that are refractory to medical management. MRI scan of the spine is not indicated.
Question 98 of 150
When performing urinary diversion, the gastrointestinal segment associated with the highest potassium loss is:
A: stomach. B: jejunum. C: proximal ileum. D: distal ileum. E: colon.
E: “colon.” was the correct answer.
It is important to know the electrolyte content of the fluid from the various bowel segments in order to replace abnormal fluid losses from these segments. Serum electrolyte complications and the type of electrolyte abnormalities that occur are different, depending on the segment of bowel used. If stomach is employed, a hypochloremic metabolic alkalosis may occur. If jejunum is the segment used, hyponatremia, hyperkalemia, and metabolic acidosis occur. If the ileum or colon is used, a hyperchloremic metabolic acidosis ensues. Hypokalemia and total-body depletion of potassium may occur in patients with urinary intestinal diversion. This is more common in patients with ureterosigmoidostomies than it is in patients who have other types of urinary intestinal diversion. The use of ureterosigmoidostomies has decreased significantly. It has been shown that ileal segments exposed to high concentrations of potassium in the urine reabsorb some of the potassium, whereas colon is less likely to do so. Thus, those with ileum interposed in the urinary tract likely blunt the potassium loss by the kidney, whereas those with colon do not, thus explaining why patients with ureterosigmoidostomies and ureterocolonic diversions are more likely to have total-body potassium depletion.
A 59-year-old man with Parkinson’s disease complains of decreased force of stream, urinary frequency, urgency, and recurrent UTI. PVR is 200 cc. The next step is:
A: uroflowmetry. B: pressure flow urodynamics. C: chronic suppressive antibiotics. D: CIC. E: TURP.
B: “pressure flow urodynamics.” was the correct answer.
Voiding dysfunction in men with Parkinson’s disease can be a result of a multitude of factors, including outlet obstruction related to the prostate, detrusor-striated sphincter pseudodyssynergia, and rarely true dyssynergia. While detrusor overactivity is the most common urodynamic finding in this population, poor detrusor contractility or areflexia may also be seen. Although chronic suppressive antibiotics, tamsulosin, and CIC are not unreasonable options, urodynamics studies should be performed prior to proceeding with any therapy, no matter how simple, to ensure that the proper course is being taken.
Question 111 of 150
A three-year-old boy who underwent a surgical correction for a high imperforate anus has inability to toilet train. VCUG reveals a large trabeculated bladder, grade 3 left VUR and incomplete bladder emptying. Ultrasound of the abdomen shows two normal kidneys. The next step is:
A: spinal ultrasound. B: spinal MRI scan. C: alpha-blocker. D: CIC. E: vesicostomy.
B: “spinal MRI scan.” is correct.
Spinal cord abnormalities, including tethered cord or thickened or fatty filum terminale and lipoma have been noted in 20-50% of patients with imperforate anus. The severity of the lesion is proportional to the severity of the rectal lesion. In this case, the patient has a high-imperforate anus. VCUG reveals trabeculation, VUR into one kidney, and incomplete bladder emptying - a collection of findings for possible neurogenic bladder dysfunction. The best test is an MRI scan to rule-out spinal cord lesions since the kidneys are presently normal and the bladder has some subtle findings. Due to ossification of the spine a spinal ultrasound cannot rule-out a tethered spinal cord after three months of life. Vesicostomy, CIC, and antimuscarinic and alpha-blocker medications are premature at this point without formal diagnosis of neurogenic bladder and urodynamic study.
Question 115 of 150
After traumatic renal injury, the predictors of persistent bleeding are depth of parenchymal injury, presence of arterial blush, and:
A: urinary extravasation. B: devitalized fragment. C: thickness of hematoma. D: location of laceration. E: mechanism of injury.
C: “thickness of hematoma.” was the correct answer.
After renal trauma, the likelihood of renal exploration, renorraphy, and nephrectomy is associated with the grade of injury. For example, Grade 4 injuries have a 64 fold higher likelihood of needing nephrectomy than a Grade 1 injury. New literature shows that for grade 3 and 4 injuries, medial hematoma, hematoma > 3.5 cm in thickness and the presence of a vascular contrast blush are associated with increased risk of bleeding and need for intervention. The presence of such findings should alert the urologist to the potential need for angiography and selective embolization of segmental vascular injuries. While urinary extravasation and devitalized fragments increase the risk of urinoma formation, they are not associated with higher rates of bleeding. Neither location of laceration or mechanism of injury predict complications independent of grade.
Question 118 of 150
In a man with azoospermia and elevated FSH, the best predictor of sperm retrieval from the testicle is:
A: serum FSH level. B: testosterone level. C: Y chromosome deletion subtype. D: seminal volume. E: presence of the vas deferens.
C: “Y chromosome deletion subtype.” was the correct answer.
In men with azoospermia, 7% will be associated with Y chromosome microdeletions. Classically, these patients will be found to have azoospermia or severe oligospermia with an elevation in FSH. The microdeletions occur in the long arm of the Y chromosome and are designated as AZFa (proximal), AZFb middle, and AZFc distal. The most common deletion is AZFc. About 75% of men with AZFc deletions have sperm on testicular biopsy. Sperm retrieval from men with complete AZFa or AZFb deletions have not been successful. The success of testicular sperm retrieval has not been correlated with FSH or testosterone level. Seminal volume does not reflect spermatogenic potential and has no relationship to the success of sperm retrieval. The absence of the vas deferens may be associated with obstructive azoospermia but these patients should have a normal FSH whereas this patient has an elevated FSH indicating non-obstructive azoospermia.
A 63-year-old woman has lethargy and joint pain four years following sigmoid neobladder creation. Serum studies reveal bicarbonate 20 mEq/l, calcium 9.1 mg/dl, alkaline phosphatase 249 U/l, hematocrit of 34%. The next step is:
A: oral calcium and Vitamin D.
B: oral magnesium and Vitamin D.
C: oral calcium and potassium citrate.
D: intramuscular Vitamin B12.
E: oral bisphosphonate.
C: “oral calcium and potassium citrate.” was the correct answer.
Osteomalacia occurs when mineralized bone is reduced and the osteoid component becomes excessive. Osteomalacia has been reported in patients with all forms of urinary diversion but is most common in colonic continent diversion and especially in postmenopausal women. The metabolic acidosis is buffered by the bone with release of bone calcium. Correction of acidosis and calcium supplementation will result in symptomatic relief and restoration of bone density. Major alterations in serum bicarbonate are not usually present and calcium is usually low normal. Patients who develop osteomalacia generally complain of lethargy; joint pain, especially in the weight-bearing joints; and proximal myopathy. The alkaline phosphatase level is elevated. Although bisphosphonates will decrease bone resorption they do not address the root cause of the problem. Vitamin B12 deficiency is not seen in colonic urinary diversion.
Question 46 of 150 (2011)
A 50-year-old man has a two year history of erectile dysfunction, urinary frequency, nocturia, and recurrent UTIs. Physical examination reveals an absent bulbocavernosus reflex and an enlarged prostate. Neurologic evaluation reveals decreased vibratory sensation in his hands and feet. A CMG shows 200 ml residual urine and first sensation at 400 ml. These findings are most consistent with:
A: multiple sclerosis.
B: Shy-Drager syndrome.
C: Parkinson’s disease.
D: herpes zoster.
E: diabetes mellitus
E: “diabetes mellitus.” was the correct answer.
The decrease in vibratory sensation of the hands and feet, a delayed first sensation at 400 ml on a CMG, and increased residual urine all favor the diagnosis of diabetic cystopathy. Urinary frequency and nocturia may also be due to an osmotic diuresis. The absent bulbocavernosus reflex is unusual but can occur in normal men. Good sphincter tone and voluntary sphincter contraction would suggest there is no abnormality in the sacral reflex. The findings presented are more consistent with undiagnosed diabetes mellitus. These urodynamic findings are not typical for Parkinson’s disease which is usually detrusor overactivity and impaired contractility. In contrast, Shy-Drager syndrome would have detrusor overactivity, open bladder neck, and denervation of the external sphincter. Herpes zoster tends to have cutaneous lesions and exhibit a dermatomal pattern, not a symmetrical neuropathy as described in this scenario.
