Urology

Question 1

Risk Factors for UTI

Answer 1

· Foreign body
	· Sexual activity
	· Obstruction
		o obstruction (calculi) – need to rule this out in men
		o prostate enlargement
	· Stasis
		o vesicoureteral reflux
		o pregnancy – incomplete bladder emptying
		o MS
		o spinal cord injury
	· Immunocompromised
		o Diabetes – because of sugar
		o sickle cell trait
		o HIV / AIDS
	· Bypassing host defenses
		o instrumentation
		o indwelling catheter

Question 2

what are UTI causing bacteria

Answer 2

· Bacteriology – think “KEEPPSS”
	· Klebsiella
	· E. coli is >80% of cultures
	· Enterococcus, enterobacter
	· Proteus, pseudomonas
	· Staph saprophyticus, Serratia

Question 3

What is the treatment of a UTI in pregnancy

Answer 3

Nitrofurantoin
amoxicillin
cephalexin
Before third semester (TMP-SMX) for 7days

Question 4

How do you treat pyelonephritis

Answer 4

o Antibiotics
§ Septra DS one tab bid X 10/7
§ Ciprofloxacin 500 mg po bid X 10/7

IV
§ Ceftriaxone 1gm q 24hr (add gentamycin if septic)
§ Ciprofloxacin 400 mg iv q 12hr
§ Ampicillin 1gm q6hr + Gentamicin 1mg/kg q8hr

Question 5

What are indications for admission with pyelonephritis

Answer 5

o Significant dehydration or ongoing vomiting
	o Immunosuppressed
	o < 3 months or elderly
	o Pregnant 
	o Structural abnormality or stone dz
Social factors

Question 6

How is prostatitis treatet

Answer 6

Cipro 500mg po bid x 30 days or Septra bid x 30 days,
if toxic appearing – IV Cipro 400mg q12h or ceftriaxone 2g q24h

chronic – usually dx as relapsing UTI caused by same organism, tx same as for acute

Question 7

Five common locations of obstruction of urinary tract

Answer 7

· Renal calyx
· Ureteropelvic junction = UPJ (1cm pelvis narrows to 2-3 mm ureter)
· Pelvic brim (ureter crosses under the iliac vessels)
· Ureterovesicular junction = UVJ (most common location for impaction)
· Vesicular orifice

Question 8

Which stones require intervention?

Answer 8

· 8/5 rule
o > 8mm in kidney requires intervention
o > 5mm in ureter requires intervention

Question 9

DDx of the acute Scrotum:

Answer 9

· From outside the scrotum
	o Hernia
	o Fournier gangrene
· From inside the scrotum
	o Testicular torsion
	o Torsion of appendix of the testicle
	o Epididymitis
	o Orchitis
	o Vericocele
	o Spermatocele
	o Hydrocele
	o Trauma
	o Tumour

Question 10

What are 10 causes of acute urinary retention in adults

Answer 10

Penis: phimosis
paraphimosis
meatal stenosis
FB

Urethra
tumor
FB
calculuc

Prostate
BPH
prostatitis

Paralysis
spinal shoch
spinal cord syndrome
MS

Drugs
Antihistamine
anticholinergic
antispasmodic
TCAs
stimulants

Question 11

What are the Two types of priapism:

Answer 11

· Low flow (aka veno-occlusive priapism)
o usually results in pain due to tissue ischemia and smooth muscle hypoxia
o this progressive ischemia results in localized necrosis, fibrosis and subsequent erectile dysf(x)
o the penis can becomes indurated and shortened over time
· High flow
o Less common than low flow
o Also seen with self-injection injuries
o Not at risk for ischemia since the blood is arterial
o Typically no pain (since no ischemia) :. Can present later

Question 12

What is the etiology of low flow pripism

Answer 12

ntracavernosal injection of a vasoactive drug – therapies for impotence
o Appears to be less common with the 3P: papaverine, phentolamine, and PGE1 therapy but still occurs
o Even less with intraurethral form of the drug but still occurs.
· Hematological Disease
o Sickle Cell Disease
o Hemoglobinopathies
o Rarely: Erythropoietin therapy, Leukemias, Myeloma
· Neurological Causes
o Lumbar disk disease
o Seizure disorders
o Cerebrovascular disease
· Post Trauma
o Trauma to the perineum, groin while usually resulting in high flow priapism may result in venous compression due to penile hematoma or edema and therefore cause a LFP.
· Tumors
o Bladder and Prostate Cancer
o Renal cell – metastatic
· Pharmacological
o Rebound hypercoaguable state after cessation of IV heparin and oral coumarins.
o Patients on hemodialysis may have rebound LFP after cessation of heparin.
o Risperidone
o Androstenedione
o Methylphenidate (ADHD) withdrawal
o Illicit drugs – Cocaine, Marijuana

Question 13

What is the etiology of high flow pripism

Answer 13

Usually associated with penile, perineal or pelvic trauma, which allows uncontrolled arterial inflow directly into the penile sinusoidal spaces (but has been seen with sickle cell dz)

Question 14

What is the treatment of pripism

Answer 14

1. TX primary cause and provide analgesia/anxiolysis
2. Try systemic therapy
   o Terbutaline 0.25-0.5 mg SQ Q20m X2 SQ (at deltoid)
   o Pseudophedrine 60-120mg PO
3. Intra-cavernosal therapy (non clear consensus on the order of the next two treatments)
   a. Aspiration/injection of the corpus cavernosum
   b. First perform a penile nerve block, injecting around the entire base of the penile shaft with 1% lidocaine without epinephrine.
   c. After anesthesia is ensured, use a 19-gauge needle attached to a large syringe and puncture the corpus cavernosum. This should be performed through the shaft of the penis laterally to avoid the corpus spongiosum and urethra ventrally and the neurovascular bundle dorsally.
   d. Aspirate 20-30 mL of blood from either the 2-o’clock or 10-o’clock position while milking the shaft. Because multiple communications exist from one corpus to the other, aspiration usually is required only on one side.
   e. If aspiration or injection is successful in producing detumescence, place an elastic bandage around the shaft of the penis to ensure continued emptying of the corpora and to compress the puncture site.
   f. Aspiration alone has a success rate of around 30%. If this procedure is not successful, phenylephrine (200mcg), epinephrine, or methylene blue (50mg) may be instilled into the corpus cavernosa.
   g. If these measures fail, surgical intervention is required