Urology

Question 1

Testicular torsion

Answer 1

Seen in young adolescents, severe testial pain of sudden onset, no fever/pyuria/recent mumps history. Testis swollen, super tender, high riding, horizontal lie. Non-tender cord. UROLOGIC EMERGENCY, dont do tests, untwist testis, orchiopexy (fix down ball)- might do both

Question 2

Acute epididymitis

Answer 2

Could think this is testicular torsion. Young men old enough to be having sex, starts w/ severe testicular sudden pain, w/ fever and pyuria, swollen testis/tender but in right place. Cord very tender. Tx antibiotics, but also sonogram to make sure no twisted ball!

Question 3

Combo of obstruction and infection of UT

Answer 3

Dire emergency! Kidney could be destroyed in hours and death from sepsis. Patient passing ureteral stone spontaneously suddenly gets chills + fever spike + flank pain. Do IV abx + immediate decompression w/ ureteral stent or percutaneous nephrostomy, defer elaborate stuff for later.

Question 4

UTI

Answer 4

Very common in women (cystitis) of repo age, frequent painful pee, small cloudy malodorous urine. Empiric antimicrob tx. Pyelonephritis or UTi in kids/men needs cultures and a urology w/u to rule out obstruction

Question 5

Urology w/u

Answer 5

Used to mean intravenous pyelogram (IVP), gives excellent view of kidney, collecting system, ureters, and bladder, shows fn for kidney, ureter, bladder (xray). But might be allergic to dye, can’t be used if limited renal fn (creat >2, dont do). Now CT and sonograms are more common for renal tumors and dilation. Only cystoscopy can look for bladder cancer in mucosa

Question 6

Pyelonephritis

Answer 6

Chills, high fever, nausea, vom, flank pain. Hospital + IV abx (from cultures), and uro w/u (IVp or songoram)

Question 7

Acute bacterial prostatitis

Answer 7

Older men w/ chills, fever, dysuria, urinary frequency, diffuse low back pain, super tender prostate. Do IV abx, dont do any more DRE. Continued prostatic massage => Septic shock!

Question 8

Posterior urethral valves

Answer 8

Newborn can’t urinate at first day (or meatal stenosis). Catheterization to empty bladder (valves not an obstacle). Do a voiding cystourethrogram to dx, and endoscopic fulguration/resection

Question 9

Hypospadias

Answer 9

Urethral opening on ventral side of penis, between tip and base. Don’t circumcise this child, b/ skin of prepuce needed for eventual plastic reconstruction

Question 10

Hematuria from trivial trauma in kids

Answer 10

Do uro w/u. Could be vesicoureteral reflux or other congen issue

Question 11

Vesicoureteral reflux

Answer 11

+ infection, make burning on pee, ffrequent, low ab/perineal pain, flank pain, fever/chills. Tx infec w/ abx (empiric, then culture guided), do IVP and voiding cystogram to look for reflux. If found, long-term abx until child grows outta problem?

Question 12

Low ureter implantation

Answer 12

Asx in little boys, but in little girls, she feels need to void and pees at normally appropriate intervals, but also wet w/ urine from urine dripping into vagina. What?? IF pe doesnt show abnormal ureteral opening, IVp shows, do corrective surgery

Question 13

Ureteropelvic junction obstruction (UPJ)

Answer 13

Anomaly at UPJ allows normal UO w/out difficult, but if large diuresis occurs, narrow area can’t handle it. Kid drinks too much beer for first time, gets colicky flank pain

Question 14

Hematuria

Answer 14

Most common presentation for kidney, ureter, bladder cancer. But most hematuria cases are benign, but unless adult w/ trace hemat post trauma, any pt needs w/u to rule out cancer

Question 15

Hemat w/u

Answer 15

IVP for renal/ureteral tumors (or CT if allergy or bad kidneys), then cystoscopy to look for bladder cancer

Question 16

Renal cell carcinoma

Answer 16

Full blown = hematuria, flank pain and flank mass. Hypercalc, erythrocytosis, elevated liver enzymes But now earlier w/u means renal mass seen on IVP, sonogram shows its solid )(not cystic). Ct gives best detail, shows heterogenic solid tumor, might grow into renal vein, vena cava. IF RCC suggested, Ct done first, surgery is only therapy

Question 17

Bladder cancer (trasitional cell mostly)

Answer 17

Close smoking correlation, usually w/ hematuria. Sometimes irritative voiding sx, pt tx for UTI even though neg cultures and afebrile. IVP and then cystoscopy, then surgery + intravesical BCG immunotherapy, high rate of local recurrence, so long term follow-up

Question 18

Prostatic cancer

Answer 18

Up incidence with age, most asx, sought by rectal exam (rock-hard discrete nodule), and PSA elevated. Stop surveillance beyond age 75. Transrectal needle biopsy (guided by sonogram), establishes dx. Ct helps assess extent/choose therapy. Can do surgery and/or rads, widespread bone mets can respond to androgen ablation, orchiectomy or medical (LH-relasing hormone agonists or antiandrogens like flutamide)

Question 19

Testicular caner

Answer 19

young men, painles mass, almost NEVEr benign, so biopsy w/ radical orchiectomy bia inguinal route. Blood samples pre-op for a-fetoprotein and B-HCG, useful for follow-up. Maybe lymph node dissection. Most testicular cancer very radio/chemosensitive, so successful tx even advanced mets yay!

Question 20

Acute urinary retention

Answer 20

Men w/ sig sx of BPH, from having a cold or using antihistamines/nasal drops and abundant fluid intake. Wants to void but cant, huge distended bladder palpable. Gotta catheter and leave in for 3 days, long-term = alpha-blockers. 5-Alpha reductase inhib for very large glands (> 40g), minimally invasive procedure under eval. TURP (transurerethral resection of prostate) is RARE now

Question 21

Postop urinary retention

Answer 21

Very common, might masquerade as incontinence. dont feel need to void b/c of post-op pain, meds, etc, but then every few minutes pee a bit. Distented palpable bladder = overflow incontinence. Catheter!

Question 22

Stress incontinence

Answer 22

Very common, in middle-age women, many pregos and vag deliveries, lead small urine when sudden intrab pressure (sneez, laugh, get out of chair, lifting heavy object), none at night. Weak pelvic floor w/ porlapsed bladder neck outside high-pressed ab area. Surg repair if advanced or if large cystoceles. Pelvic floor exercises could be enough

Question 23

Passage of ureteral stones

Answer 23

Classic colikcy flank pain, irradiation to inner thigh/labia/scrotum, nausea/vom. See stone on x-ray, then IVP or CT for further definition. Don’t always need to intervene, smaller than 3 mm pass 70% of time on own, just give analgesics, lotsa water, waitch. 7 mm stone at UPJ probs won’t pass, so use ESWL (shock-wave lithoripsy), but can’t use in pregos, bleeding diathesis, stones too big, so then basket extract, sonic probes, laser beams, open surgery. DRINK WATER

Question 24

Pneumaturia

Answer 24

From fistulization between bladder and GI tract, often sigmoid colon diverticulitis (or sigmoid cancer, or bladder cancer, more rare). W/u with Ct scan, shows inflamm divertiular mass, sigmoidoscopy later to rule out cancer. Do surgery

Question 25

Impotence

Answer 25

Organic or psychogenic. Psychogenic = sudden onset, partner/situation specific, postage stamp test if sychogenic. Organic impotence if traumatic = sudden. Chronic disease (arteriosclerosis/diabetes) very gradual onset, erections dont last long enough, then poor quality, then none :( Use sildenafil, tadalafil, vardenafil as first choices, or vasc surgery, suction devices, or prosthetic implants (not a good idea)