Urology Flashcards

Question

VUR dx

Answer 1

* VUR is dx when UTI is suspected * Urinalysis =\> Urine culture – check for UTI * US – shape and size but can’t detect reflux * Cystourethrogram (cystogram) – post UTI tx, dx VUR (fills bladder w/dye and then x-ray images of bladder filling & voiding)

Answer 2

Using cystogram * Grade 1 = urine back into ureter * Grade II = urine back into renal pelvis & calyces * Grade III = urine back into collecting system, mild ureter and pelvic dilation w/mild calyces blunting * Grade IV = urine back into collecting system, moderate ureter and pelvic dilation w/moderate calyces blunting * Grade V = urine back into collecting system, severe ureter and pelvic dilation w/severe calyces blunting * Grade IV-V = indicated for surgery

Answer 3

* Mild cases spontaneously grow out of it by age 5 & do not require tx * If tx is needed abx (amoxicillin or trimethoprim-sulfamethoxazole (BACTRIM)) – prophylactically or as needed * Severe cases or recurrent UTI while taking abx will require surgery (create new valve)

Answer 4

* Grade IV-V * Persistent reflux despite medial tx (\>3) * Breakthrough UTIs w/receive abx prophylaxis * Lack or renal growth * Multiple drug allergies the prevent them to use abx * Medical noncompliance

Answer 5

1. Prostatitis = urine reflux =\> tender enlarged prostate, fever 1. mc UTI (gram neg = E.coli, Proteus, Klebsiella, Enterobacter, Pseudomonas), STI less likely 2. Acute cystitis = frequency, dysuria, urgency, nocturia, fever less prevalent 3. Acute pyelonephritis = more dramatic presentation, high fever, chills, flank pain + urinary sxs 4. Orchitis = epididymitis (STI)/viral =\> orchitis =\> heavy aching testis, frequently enlarged, not present w/ urinary sxs, 5. Urethritis = STI =\> urethral discharge, dysuria, frequency (Chlamydia = watery, Gonorrhea = thick)

Answer 6

* UTI = does nt present w/systemic sxs (fever/chills) * Pyelonephritis = less likely since no CVA tenderness * Nephrolithiasis = present w/localized sxs, unlikely to be bilateral * Acute prostatitis = fever, chills, malaise, myalgia, dysuria, pelvic or perineal pain, cloudy urine. Tender & edematous prostate. * Isolated acute cystitis does not common in men! Virtually all UTIs in mend are due to prostatitis. Mc = E. coli & proteus (gram -) * RF = BPH, GU instrumentation predispose pts for UTI * Early tx prevent prostatic abscess & sepsis * Prostate CA = elevated PSA more likely due to acute prostatitis, derfer serum PSA evaluation for a month after acute prostatitis

Answer 7

* No tx bc asymptomatic = WRONG * Renal US = for serious infections like pyelonephritis or to look for complciations cush as hydronephrosis or abscess * Admission + IV abx = for serious infections like pyelonephritis * \*\*\*Oral abx + short interval FU = 10% pregnant women present asymptomatically and UTI is associated w/ preterm & low birth weight.

Answer 8

* Renal US = renal calculi & unilateral hydronephrosis consistent w/ obstructing calculus, but can’t image entire ureters. It is first line for pediatric or pregnant * Abdominal radiograph (upright) = large radiopaque stones, miss uric acid stones, small stones, or stones overlying bony structures. * Abdominal/Pelvic CT scan = visualize calculus but inferior to renal stone protocol. * Renal stone protocol CT = noncontract helical CT, reduce dosage & position in prone to remove deponent bladder calculi from UVJ to prevent misstating freely mobile bladder calculus for UVJ obstructing stones.

Answer 9

diabetic, unilateral flank pain, 103.5 F (high fever), low BP * Dx = CT shows air in renal parenchyma * Tx = medical emergency, rapidly fulminating – moderate/severe cases req emergent nephrectomy

Answer 10

collecting system (renal pelvis & ureter w/o renal parenchymal involvement) inflammation * Caused by infection or stone disease, no gas present

Answer 11

dilated collecting system, w/clear source of obstruction (mass, stricture, stone)

Answer 12

focal renal mass/diffuse parenchymal infiltration/perirenal adenopathy * Chronic process

Answer 13

rare, w/nonspecific imaging in acute stage, resembles non complicated pyelonephritis w/low density adenopathy. In chronic cases, chronic renal failure w/atrophic & scarred kidney +/- dystrophic calcifications

Answer 14

1. delayed UTI tx =\> ascending UTI or Ureteral flow obstruction (paritipartialucting calculus) 1. Microbes = E. coli (75-95%), Proteus, K.pneumoniae 2. UTI sxs, fever, unilateral CVA tenderness 1. Sepsis, acute renal failure, vague sxs (malaise/abdominal pain) 3. Labs/Orders 1. Urinanalysis (visual, dipstick, microscopic) 1. infection = \> 20 WBCs/hpf & 100,000 CFU & white cell casts 2. Urine culture 3. CT & US evaluate underyling anatomic abnormailites or detect complications (calculus, abscess) 4. Complicated pyelonephritis = admitted & given parenteral, broad-spectrum abx, then narrowed after urine culture. Abx administered 10-14days.

Answer 15

1. Needle-shaped = uric acid 2. Bipyramidal & biconcave crystals = calcium phosphate/oxylate 3. Coffin-shaped (rectangle) = staghorn 4. Hexagon = cystine

Answer 16

alkaline pH = staghorn, calcium phosphate acidic pH = calcium oxalate, uric acid,

Answer 17

1. **Aromatic Amines** from rubber & analine dye industry =\> **bladder ca.** 1. Bladder CA risk factors, Φ familial syndrome 1. Environmental = Smoking, chemical exposure (aniline dyes, aluminum, paint, petroleum, rubber, textiles), diet rich with meat & fat. 2. Iatrogenic = Pelvic radiation, Cyclophosphamide (CXT), Chronic cystitis (indwelling catheters) 3. Geography = Africa/Middle east =\> Schistosomiasis (snails) =\> Squamous cell bladder cancer 2. **Alkylating agents** = **chemo** agent (cyclophosphamide & chlorambucil) used to **tx variety of cancers**. Does not increase risk of 2ndary malignancy due to their effect on changing DNA structures. 3. **polycyclic hydrocarbons** = produced after **tobacco** combustion =\> **lung ca** 4. **aflatoxin B1** = fungal sp (aspergillus flavus) on grains & peanuts ingestion in mostly Asia =\> **hepatocellular carcinoma** 5. **nitroamines** = **food perservatives, salted meats, pickled foods** common in asia =\> **gastric carcinoma and GI ca.**

Answer 18

1. **Prostatitis** = urine reflux w/G- =\> fever, pain, prostate tenderness 2. **Prostate ca** = peripheral =\> silient, rarely grows to completly obstruct urethra =\> elevated PSA. If palpable, hard nodule. 3. **Cystitis** = rarely in men, same mec as prostatitis =\> hematuria and Lower tract sxs but not painless urinary retention 4. **_Chronic bladder outlet obstruction_** = sxs are classic for prostatic hyperplasia. Nodular contour can be 2ndary to BPH nodules. 5. **Renal failure** = would cause acute rather than chronic sxs. Bladder would be minimally distendend

Answer 19

Blood in Urine dipstick may represent hemoglobin or myoglobin. Myoglobin can be elevated post exercise and is benign. 1. Glomerulonephritis = paucity of RBC, no rbc casts 2. Myoglobinuria = If dipstick shows + for blood, perform microscopic analysis. 3. Hematuria = paucity of RBC 1. microscopic hematuria = \> 3 RBC/hpf 4. Trauma = low RBC count, no hx of trauma 5. UTI = no WBCs and neg. leukocyte esterase

Answer 20

1. **Acetazolamide** = carbonic anhydrase inhibitor, minimal effect on renal Ca+ 2. **Hydrochlorothiazide = Thiazide diuretics are the only class that decrease urinary secretion of Ca+** 3. **Furosemide** = loop diuretic. Blocks action of Ka, K, 2CL cotransporter. Causes inc. Na, K, Ca in urine =\> inc. stone production 4. **Triamterene &** **Spironolactone** = K+ sparing diuretics. Block Na/K exchange in collecting duct, decrease K+ secretion, but elevate Na+ & Ca2+ secretion =\> inc. stone production

Answer 21

Retain (in body), Secrete (in urine) 1. **Acetazolamide** 1. Retain = creatinine, abx, diuretics, **uric acid** 2. Secrete = carbonic anhydrase (NaHCO3), **glucose, AA** 2. **Osmotic = Mannitol** 1. Retain = **water** 3. **Loop diuretic = Furosemide, Bumetanide, Torsemide, Ethacrynic Acid** 1. Secrete = Na+, K+, 2Cl- (cotransporer blocked) =\> Mg2+, Ca2+, K+ (dragged by cotransporter) 4. **Thiazide** = **C****hlorothiazides** 1. Retain = only class that decrease urinary secretion of **_Ca+_** 2. Secrete = Na+,Cl- 5. **Aldosterone antag "K+ sparing diuretics" = Amirloride, Triamterene, Spironolactone** 1. Retain = K+ 2. Secrete = Na+, Cl- (Block Na/K exchange), Ca2+ follows Na+

Answer 22

This is emphysematous pyelonephritis is a necrotizing infection w/gas production involving renal parenchyma, and in some cases perirenal tissue. * emphysematous cystitis & pyelitis (gas in renal pelvis) can also ocur * infection usually due to E.coli, K.pneumoniae * DM major risk factor of UTI to progress to emphysematous pyelonephritis 1. **IV** **abx** **& Interventional radiology consultation for percutaneous nephrostomy** = pts w/emphysematous pyelonephritis _w/o extra-renal involvement_ 2. **Surgical consultation (nephrectomy or open drainage)** = pts w/_extra-renal_ involvement or fail IV abx w/percutaneous nephrostomy. 3. **Hospital admission & abx PO; Extended abx PO** = oral abx not sufficient for pyelonephrtis 4. **Hospital admission & parenteral abx** = pts w/emphysematous pyelitis

Answer 23

In older men BPH =\> bladder outlet obstruction =\> UTI 1. **Oral abx **= UTI **(longer abx course than women)** 2. admit + IV abx = pyelonephritis (high fever, flank pain, rigors, eventually sepsis) this is a medical emergency 3. US & CT = complications of cystitis or pyelonephrtis (eg abscess)

Answer 24

LUTS = obstructive and irritative sxs (occur in both sexes with age) 1. Obstructive sxs WISE = **W**eak stream, **I**ntermittent stream, **S**train, incomplete **E**mptying 1. Urethral strictures 2. Irritative sxs FUN = **F**requency, **U**rgency, **N**octuria 1. Bladder tumors 3. Both = BPH

Answer 25

Nl prostate secretes enzymes (PSA) that liquefy semen & enlarges with age. * *Anterior zone = fibromuscular & non-glandular* * ***Peripheral zone** = acinar =\> carcinoma* * Close to rectum, felt during DRE * *LUT sxs only in late phase, hard & firm prostate* * *Central zone = proximal urethra, internal urethral sphincter* * ***Transition zone** = urethra =\> BPH* * Around urethra, not easily felt during DRE * *LUT sxs, rubbery smooth or nodular prostate*

Answer 26

Most men by age 80 have enlarged prostate which is normal. BPH can cause retention =\> recurrent UTI =\> bladder/renal calculi, hydronephrosis =\> kidney damage

Answer 27

HPI 1. Aging =\> epithelial & smooth muscle hyperplasia in Transition Zone (BPH) =\> obstructs urethra =\> lower urinary tract sxs (LUTS) 2. LUTS = obstructive (WISE) and irritative (FUN) sxs 3. +/- Hematuria PE 1. **DRE =** rubbery, uniform enlargement = BPH transition zone =\> +/- detectable on DRE 1. hard/irregular lesion = prostate ca mc peripheral =\> detectable on DRE 2. **Neurologic** = normal sphincter tone, perineal sesnation, and sacral reflexes (knee & ankle jerks)

Answer 28

1. **International Prostate Symptom (IPSS)** 1. 0-7 mild 2. 7-15 moderate 3. \>15 severe 2. **UA & Urine culture** to rule out infection & hematuria 1. Hematuria (\>3 RBC/hpf) on urine microscopy w/o infection =\> refer to urologist for hematuria WU to rule out ca 3. **Voiding diary** 4. **Serum Creatinine** to rule out obstructive uropathy & renal insufficiency At Urologist 1. **Uroflowmetry** (measure urine flow rate) = assess severity of BPH 1. **Low flow rate (\<10 cc/sec)** = urethral obstruction (BPH, stricture, tumor) or poor bladder contractility 2. **Postvoid Residual (PVR)** = assess incomplete emptying or urinary retention 1. catheter placed post void & measured w/US (not very reliable) 2. **Low PVR (\<50** **cc****)**can**rule out** incomplete emptying or urinary retention 3. **Urodynamic** (cystometry, pressure-flow analysis) = assess compacity, compliance, contractility of bladder/ degree of obstruction/ neurologic 1. Indications 1. Rx refractory BPH, considering surgical tx 2. Neurologic etiology (spinal cord injury, prolapsed lumbar disk, etc.)

Answer 29

1. 1st line = **Alpha (adrenergic) blockers** =\> relax smooth muscle =\> open prostatic urethra 1. Tera**_zosin_** (2mg PO QHS, over few wks, increase dose to 8-10mg), Doxazosin, Tamsulosin (flomax) 2. SE = **Dizziness**, HA, Fatigue, Nausea 3. Decongestants (Sudafed = pseudoephedrine) is adrenergic agonists =\> increase LUTS 2. 2nd line = **5a-reducatase inhibitors** =\> reduce dihydrotestosterone production =\> reduce acinar-glandular volume 1. Finaste**_ride_** - Proscar 2. Reserved for LARGE prostate, and takes 6 mos to shrink volume

Answer 30

1. Perform **Urodynamic evaluation** - confirms sxs are due to obstruction not from neurologic problems or poor contracting bladder 2. 3rd line = **Surgery** 1. _Indications_ = Rx refractory, recurrent urinary retention, obstructive uropathy or bladder stones from bladder outlet obstruction, desire to avoid meds. 2. **Transurethral resection of prostate (TURP)** = gold standard for prostatic obstruction from BPH 3. **Transurethral Microwave thermotherapy (TUMT)** = less effective, use for cardiac risk/co-morbidities 4. **Transurethral radiofrequency needle ablation of prostate (TUNA)** = less effective, use for cardiac risk/co-morbidities 5. **Open simple prostatectomy** = very large prostates \> 100 grams or bladder damaged/stones, does not remove entire prostate 6. **Open radical prostatectomy** = NOT for BPH, only for prostate ca

Answer 31

1. **Prostatitis** = prostatic edema & swelling =\> increase bladder outlet resistance 2. **Narcotics** = reduce bladder contractility 3. **Diphenhydramine** (Benadryl) = anti-histamine with significant anti-cholinergic effects =\> reduce bladder contractility 4. **Pseudoephedrine** (Sudafed) = sympathomimetic =\> stimulate alpha receptors in prostate =\> increase resistance at prostatic urethra 5. **Oxybutynin** (Ditropan) = strong anti-cholinergic used to tx bladder spasms and over activity. Men should generally not be given this medication without consulting a urologist. **Tolterodine** (Detrol) is a similar medication. 6. **Alcohol ingestion** = trigger urinary retention; the exact mechanism is not clear. 7. **General and particularly Spinal Anesthesia** = paralyze bladder which often results in post-op urinary retention.

Answer 32

1. **Decompress bladder** = catheterize and drain urine (nl bladder holds 500 cc) 2. **RU serious obstructive uropathy** = measure creatine (nl .6-1.2 mg/dL) 3. **Tx** = Start alpha blocker 4. **Assessment/Plan** = Refer to urologist for voiding trails in 3-7 days. 1. alpha blockers require 72 hrs to reach optimal levels and allow bladder to recover muscle contractility 2. 50% will pass the voiding trial after an episode of acute retention, thus avoiding TURP * Suprapubic tube provides no added benefit compared to urethral catheterization * Mildly elevated serum creatinine is fine, it will drop to normal post decompression * Finasteride (takes 6 mos) not helpful in acute setting * All men w/ retention should be referred to urologist for FU

Answer 33

**\> 1,000 cc urine & elevated creatine are at risk for _post-obstructive diuresis_** 1. Diagnostic POD = urine production... 1. \> 3L/24hrs 2. \> 200 mL/hr for 2 consecutive hours or 2. Treatment is the same 1. Decompress = urethral catheterization (foley) 2. **Replacement fluids (limit to 75% of prev. hourly urine output until polyuria normalized) &** **Monitor** **(serum & urine electrolytes)** 3. Alpha blockers **+ 5 alpha reductase inhibitors** 4. Refer to urologist in **7 days** = void trial (more likely to fail)

Answer 34

* surgery = TURP, laser TURP, Urolift * Long term intermittent self catheterization (permanent. foley catheter) or supapubic (S/P) tube = severely damaged or atonic bladders

Answer 35

1. lung ca 2. prostate ca 3. colorectal ca 4. pancreatic ca 5. liver & biliary duct

Answer 36

MC ca & 2nd leading ca death (after lung ca) in men Age, + FH, African Americans

Answer 37

1. False + = cystoscopy, bx, BPH, UTI, prostatitis, Ejaculation 2. PSA values 1. Absolute PSA reference = 40's (2.5ng/mL) - 70's (6.5ng/mL) * **10ng/mL** = likely to metastasize 2. **PSA density** = prostate volume/absolute PSA levels (volume measured by TRUS or MRI) * ≥.**15ng/ml indication for bx** 3. **PSA Velocity** = 3 measures obtained over 2 yrs 1. **.35ng/ml/yr rise if \<4ng/ml** 2. .**75ng/ml/yr rise if \>4ng/ml** 4. **Free PSA** 1. **\< 10% indications for bx**

Answer 38

HPI = slow-growing malignancy, stepwise disseminates (prostate =\> pelvic lymph nodes =\> spine and pelvic bones) 1. **Early/local** = **Asymptomatic** (not tender), **DRE** hard/irregular lesion (late), elevated PSA 2. **Advanced/metastatic** 1. **Locally advanced** (spread beyond prostate) =\> **LUTS** 2. Retroperitoneal (adenopahty d/t nodal mets) =\> **Lower extremity edema** (Obstruction lymphedema) 3. **Low back pain w/wo pathologic fx** (mets to bone) =\> elevated alkaline phosphatase, PSA, PAP PE 1. DRE - most ca found w/normal DRE 1. Normal rectal findings: **3-4 cm, non-tender, symmetric, smooth, rubbery, walnut shaped prostate;** Strong sphincter tone, no rectal mass; Heme (-) stool 2. Abnormal = enlarged, non-tender, irregular/asymmetric, hard, nodule(s) 2. Complete exam 1. Distended bladder (outlet obstruction) 2. Bone pain 3. Lower extremity lymphedema or DVT 4. Neurologic due to cord compression 5. Cachexia

Answer 39

DRE screening, generally 50-55 yo PSA screening = Always shared decision making for 1. **American Academy of Family Physicians & US prevention** = No PSA or DRE 2. **American Cancer society (2010)** = 50 yo (45 yo for high risk) 3. **American college of physicians (2013)** = 50-69 yo w/life expectancy \> 10 yrs 4. **American urological association (2013)** = 55-69 yo w/life expectancy \> 10 yrs (40 yrs for high risk)

Answer 40

1. Labs 1. LUTS = always check PSA 2. Asymptomatic = check PSA if screening is indicated 3. CBC, chemistry profile (alk phos), LFT 4. UA, Urine culture 2. **Trans-rectal US (TRUS) guided Bx** (diagnostic) 1. **Indications** + DRE and/or + PSA 1. ****+ DRE = enlarged (\>4 cm) or asymetric/nodular or firm 2. + PSA = age specific increase \> 4 ng/mL, % free \< 15% 2. **TRUS bx** = **Gleason** Pathologic staging mc adenocarcinoma (glands) 1. Score \< 8 = less aggressive 2. Score 8-10 = aggressive 3. **Imaging** = Bone scans, CT scans, MRI scans 1. **Indications** high risk (1 of following) 1. PSA \> 10ng/dl (spread to seminal vesicles) 2. Poorly differentaited (Gleason 8-10) 3. DRE stage ≥ T3 4. inc alk.phosphatase or bone pain

Answer 41

1. Step wise spread: prostate =\> pelvic LNs =\> spine =\> pelvic bones =\> direct extension to bladder (rare) or lungs (advanced) 1. ca is slow to progress, tx depends on aggressiveness 2. **Gleason grade** (sum of 2 most dysplastic samples 1-5; 3 + 5 = 8 better px than 5 + 3 = 8) 3. *TNM stage* 4. **Bone scan** for mets (**osteoblastic** or high bone density), CT, MRI, 40% met @ sxs presentation

Answer 42

strongly suggest prostate cancer has **not spread** and is **confined to** **prostate**. * 1)small localized nodule; 2) relatively low PSA (nl for 64 = 4.5ng/dl); 3)low volume; 4)Gleason 6 low aggressiveness Tx for localized prostate ca 1. **Active surveillance** = low volume, low risk (grade 1-6) 2. **Brachytherapy (seeding) =** low-volume, moderately risks (grade 7). not an appropriate option for very large glands. 3. **Radical prostatectomy** = \< 75 yo old who is healthy & has \> 10-year life expectancy 4. **External beam radiotherapy** = older (\>75 years old) and/or have major comorbidities.

Answer 43

1. Signs and symptoms of advanced & metastatic prostate cancer = elevated PSA, urinary retention, bone pain. 2. Once metastasized local tx do not work 3. 1st line = hormone therapy. 1. **Medical castration** (gold standard) = **goserelin** (Zoladex) & **leuprolide** (Lupron). 1. High PSA (not pulsatile) tx of **gonadotropin** **releasing-hormone** **agonists** shut down sex-hormone axis =\> eliminate testosterone production 2. **Bilateral orchiectomy** 4. Later therapies = ketoconazole, prednisone, chemo, immunotherapy

Answer 44

1. both _radical prostatectomy_ and _radiation therapy_ (external beam and brachytherapy) =\> **urinary incontinence** and **erectile dysfunction** 2. dec. libido, gynecomastia, etc...

Answer 45

Etiology = Majority are mixed incontinence 1. Bladder dysfunction * Urge incontinence = **detrusor overactivity** (non-/neurogenic), **poor compliance** * Overflow incontinence 2. Urethral dysfunction * Stress incontinence = **anatomic** (due to mobility of the bladder neck); **intrinsic sphincter deficiency** (due to bladder neck dysfunction) 3. Transient causes "reversible" - DIAPPERS * **Delirium** * **Infection** * **Atrophic vaginitis** * **Pharmacologic** * **sedatives** (ROH, benzodiazepines), * **diuretics** (overwhelm bladder volume & uninhibit detrusor contractions), * **anticholinergics** (retention =\> frequency, overflow incontinence), * **a-adrenergic** (bladder neck & proximal sphincter contraction \*used to tx prostatism =\> retention), * **a-antagonists** (smooth m. of bladder neck & proximal sphincter relax \*used to tx HTN =\> exacerbate stress incontinence in women) * **Psychological (depression)** * **Excessive urine production** = ↑ intake, DM, hypercalcemia, CHF, peripheral edema =\> polyuria * **Restricted mobility** * **Stool impaction**

Answer 46

HPI 1. **Sxs** = urgency, frequency, nocturia, unable to reach the toilet with urge, leakage w/physical activity 2. **Characteristics of incontinence** (stress, urge, pad use) 3. **Comorbid conditions** (DM, depression, constipation, prolapse, atrophic vagina)\ 4. **Medications** 5. Prior pelvic surgeries /radiation 6. **Pelvic prolapse** sxs (recurrent UTI, vaginal fullness/pressure, see bulge in vagina) PE 1. **pelvic exam** = vaginal epithelium condition, **bladder neck mobility, + stress test** (patient coughing/straining =\> urethral leakage), pelvic organ prolapse 2. **both brief neurologic survey** = rectal exam to evaluate sphincter tone & perineal sensation

Answer 47

**Urinalysis** = hematuria, pyuria, glucosuria, or proteinuria. * Cultured if there is pyuria or bacteriuria. Tx infection before further investigations/interventions. **Functional studies** * **Post void** **residual** (PVR) = measured by ultrasound or direct catheter * Normal PVR \< 50 mL * PVR \> 200 mL w/urinary sxs =\> bladder outlet obstruction or poor bladder contractility – distinguish by functional urodynamic testing * **Voiding diary** = quantitate amount of fluid intake/void, # of voids/incontinent episodes * **Urodynamic testing** = examine bladder compliance, detrusor overactivity, urethral function, rule out obstruction as a cause of either overflow or urgency incontinence. * performed prior to invasive therapies and indicated in patients undergoing repeat procedures following failed treatments.

Answer 48

* 1st line = Behavioral Changes * **avoidance of bladder irritants** * **timed voiding** * **fluid management** * **pelvic muscle exercises** * 2nd line = Medical Therapy * alpha agonists (↑ smooth muscle tone in bladder neck and proximal urethra) * anticholinergics (relax smooth muscle) * beta 3 adrenergic receptor agonists * 3rd line * Botox * Percutaneous tibial nerve stimulation * Sacral neuromodulation

Answer 49

* 1st line = Behavioral Changes * **timed voiding** * **fluid management** * **pelvic muscle exercises** * **weight loss** * 2nd line = less invasive * Pessaries * Urethral bulking agents * 3rd line = surgical * Retropubic suspensions – Midurethral synthetic sling – Pubovaginal sling

Answer 50

* Urge Incontinence (overactive bladder) = bladder pressure sufficient to overcome sphincter mechanisms * **Detrusor overactivity** mc elderly +/- bladder outlet obstruction * ↓ **Bladder compliance** due to viscoelastic loss in bladder/change in neural-regulatory activity 1. **Sxs** = urgency, frequency, nocturia, unable to reach the toilet with urge 2. **Tx** = **Overactivity** (behavioral & ant-muscarinic), **Compliance** (decrease pressure by intermittent catheterization & anticholinergics +/- Botox) * **1^st line Behavioral** = avoid bladder irritants, timed voiding, pelvic muscle exercises, weight loss * **2^nd line Anticholinergics – Antimuscarinics** * **Nonselective for M3 Receptor** * propanthel**ine** (Pro-Banthine) = 7.5 to 30 mg orally, three to five times daily * tolterod**ine** (Detrol LA) = 4 mg orally daily * trospium (Sanctura) = 20 mg orally two times daily * soli**fenacin** (Vesicare) = 5 – 10 mg orally, daily * **Selective for M3 Receptor** * dari**fenacin** (Enablex) = 7.5 – 15 mg orally, daily * **Smooth Muscle Relaxant** * oxybutynin * regular (Ditropan) 2.5 to 5 mg orally, one to three times daily * extended release (Ditropan XL) 5 – 30 mg orally, daily * transdermal (Oxytrol) 4.9 mg patch twice per week * hyoscyamine (Levsin) = 0.125 to 0.375 mg orally, two to four times daily * **Side effects** = urinary retention, dry mouth, constipation, nausea, blurred vision, tachycardia, drowsiness and confusion, contraindicated for narrow-angle glaucoma. * Surgical * Neuromodulation w/sacral nerve stimulator/bladder augmentation = refractory * Botulinum toxin injection = idiopathic, refractory OAB.

Answer 51

Incomplete bladder emptying = **obstruction/extreme volume** (urethral stricture, prostatic, pelvic prolapse) or **poor bladder contractility (viscoelastic dysfunction).** 1. **Sxs** = urgency, frequency, nocturia, leakage w/physical 2. **Signs** = high post void residual 3. **Tx obstruction** = surgery 1. urethrotomy/urethroplasty (urethral stricture) 2. Transurethral resection “TURP” (prostate obstruction) 3. Urethrolysis/surgical correction (post-surg obstruction/pelvic prolapse) 4. Intermittent catheterization (pts contraindicated for surgery) 4. **Tx poor detrusor contractility** = intermittent catheterization

Answer 52

Urethral Dysfunction = usually a combo of **urethral hypermobility** “anatomic” & **intrinsic sphincter deficiency** 1. **Etiology** 1. **Urethral hypermobility** = displaced proximal urethra below level pelvic floor =\> inappropriate transmission of abdominal pressure =\> inappropriate closing urethra =\> leak 2. **Intrinsic sphincter deficiency** = proximal smooth muscle sphincter of bladder neck dysfunction =\> severe stress incontinence. 2. **Sxs** = leakage w/physical activity (cough) 3. **Signs** = bladder neck mobility; positive stress test 4. **Treatment** * **Behavioral** = pelvic muscle exercises, weight loss, quitting smoking * Medication * **a-agonists** (↑ smooth muscle tone in bladder neck and proximal urethra) * pseudoephedrine (Sudafed) x 2 daily or 1 hr prior exercise * **Surgery** * **Anatomic** = retropubic suspensions (Burch, Marshall Marchetti Krantz), Slings (pubovaginal, midurethral, obturator, mini slings) * **Intrinsic Sphincter Deficiency** = **Slings** (pubovaginal, midurethral, obturator), **artificial sphincter**, **bulking agent injections** into submucosa (collagen (Contigen), calcium hydroxyapatite (coapatite), others)

Answer 53

1. **Obstructing renal** or **ureteral stone** 2. **Hydronephrosis** (ureteropelvic junction obstruction, stricture, ureteral/ renal malignancy) 3. **Bacterial cystitis** or **pyelonephritis** 4. **Acute abdomen** (bowel, biliary, pancreas, or aortic abdominal aneurysm) 5. **Radicular pain** (L1 herpes zoster, sciatica) 6. Depending on the patient gender, primary gonadal pathology 1. **Women**: ectopic pregnancy, ovarian torsion 2. **Men**: testicular torsion, orchitis

Answer 54

Bipyramidal or biconcave crystals = calcium phosphate (5-10%) calcium oxalate (80% kidney stone) * Calcium oxalate = acidic pH * Calcium phosphate = alkaline pH * RF = Hypercalciuria, hyperoxaluria, hypercitraturia, hypomagnesuria, renal phosphate or renal calcium leak, hyperparathyroidism, increased calcium absorption from intestines.

Answer 55

Hexagon shaped crystals = Cystine stones (1% kidney stones) * rare genetic disorder * RF = rr genetic condition (cystinuria) prevent renal tubular reabsorption of cystine, ornithine, lysine, argine. * Dx = CT w/o contrast

Answer 56

Needle-shaped, negatively birefringent crystals = large amts of cell breakdown products or meat =\> uric acid =\> uric acid stones (6% of kidney stones) * acidic pH * RF = Chemo (leukemia, lymphoma, met breast ca), Gout =\> hyperuricemia * Dx = CT w/o contrast; US or intravenous pyelogram (IVP)

Answer 57

Coffin-shaped crystals = urea =\> ammonia =\> bind phosphate and magnesium =\> calculus =\> staghorn calculi “struvite stones” (15% renal stones) * infection to kidney * RF = UTI grom G-, urease + (proteus, pseudomonas, klebsiella) * Dx = CT w/o contrast

Answer 58

* Stone recurrence rates approach 50% at 10 years * Caucasian males have the highest incidence in the US * Incidence highest in the “Stone Belt,” ie southeastern and central southern US

Answer 59

HPI = Renal colic * Intense episodic, acute unilateral flank pain w/radiation to groin * May localize to abdomen overlying stone * As stone moves, pain moves * UVJ may mimic cystitis * N/V PE * Fidgety “can’t get comfortable” * CVA tenderness

Answer 60

Labs 1. Urinalysis = essential for etiology 1. Hematuria (90% of time) – absence does not rule out stone; Crystaluria, pH 2. Rule out infection = Nitrite, leukocyte esterase; Bacteria and WBC on microscope 2. Culture 3. Serum studies = Chem 7 for Cr, CBC (WBC) Imaging = DIAGNOSTIC 1. **CT scan (****noncontrast****) = Gold standard (even for acute)** 2. KUB abdominal radiograph = 70-90% stones radioplaque (except uric acid stones, req CT) – surveillance 3. US = “posterior shadowing” High specificity, Low sensitivity – surveillance 1. Children & pregnant; Not ideal for ureteral stones or stones \< 5mm 4. Intravenous Pyelogram (noncontrast CT) = Less specificity, Less sensitivity 1. Not ideal of stones, better for looking at anatomy

Answer 61

* Obstructed upper tract with infection (fever, elevated WBC, signs of infection on urine analysis and microscopy) * Impending renal deterioration (as in a solitary kidney) * Pain refractory to analgesics * Intractable nausea/ vomiting

Answer 62

* Placement of a ureteral stent/ percutaneous nephrostomy tube to decompress the kidney * DON't break up stone, as bacteria are often housed within the stone and this could worsen urosepsis 1. Hydration = for dehydration, not improve rate of stone passage 2. Meds = narcotics, NSAIDs (NSAIDs better than narcotics, but contraindicated for AKI) CT =\> (IV fluids + anti-emetics for dehydration) + (IV pain control avoid ketorolac due to AKI) =\> pain undercontrol and afebrile =\> safe to discharge =\> hydromorphone (pain) + tamsulosin (alpha blocker “flow max”) =\> strain urine for stone =\> f/u 2 wks w/ KUB

Answer 63

Chronic Tx 1. Newly dx ureteral stone \< 10 mm w/sxs controlled can be managed (4-6 mm will pass spontaneously 50% of the time) =\> Follow with periodic imaging 2. After 1-2 mo stone unlikely to pass spontaneously – refer to urology for consult 3. **Medical Expulsion Therapy (**MET) = controversial, may shorten duration of stone passage/decrease pain 1. Adjunct to follow up pts with stones in the ureter 2. Only for pts who are well controlled pain & adequate renal function 3. Alpha blockers (tamsulosin, terazosin, doxazosin) “flowmax” 4. Calcium Channel blockers (Nifedipine) – NOT as good as alpha blockers

Answer 64

1. Urine saturation =\> supersaturation =\> crystal nucleation =\> aggregation =\> retention and growth 2. Formation relies on local environment = concentration of ions, urine pH, complexation w/ substance, volume of diluting agent (urine)

Answer 65

Most stones are mixed 1. Calcium oxlate stones (70%) 2. Uric acid 10% (radio-lucent) 3. Struvite 10% (rectangle) 4. Cystine stones (hexagon) * Inherited (rr) gene for cystine transport * More soluble at high pH (9.6) = too high, therefore goal is pH \> 7

Answer 66

Calcium oxalate stones 70% (square, X) * Initial buildup of calcium phosphate in terminal collecting duct =\> erosion of CP through urothelium =\> Nidus for calcium oxalate deposition =\> grows until too heavy to anchor and falls off the papilla * Hypercalciuria * Hyperparathyroidism (hypercalcemia) * High sodium intake * High animal protein intake (acid load) * Hyperoxaluria * Oxalate rich foods (spinach, beets, roots, nuts) * Increased oxalate absorption (low Ca+ diet, malabsorption – diarrhea/IBS/gastric bypass) * Gastric bypass “perfect storm” * Decreased fat absorption =\> less calcium bound to fat =\> less calcium in gut =\> less oxalate bound to calcium =\> less calcium and oxalate excreted in stool * Hypovolemia from fluid loss =\> supersaturation state * Metabolic acidosis from HCO3 loss in stool =\> liver converts serum citrate to HCO3 =\> hypocitraturia * Hyperuricosuria * Heterogenous nucleation * High animal fat diet =\> high purine =\> Increased uric acid * Hypocitraturia = Less “stone blocker” * Treatment = Dietary changes (inc. water intake and citrus, dec. sodium, animal protein, oxalate rich foods)

Answer 67

Uric acid 10% (radio-lucent) * Treatment = alkalinize urine (potassium citrate) * Acidic urine pH \< 6 * Chemotherapy-tumor lysis (lymphoma or leukemia) * Product of purine metabolism

Answer 68

Struvite 10% (rectangle) * Urease producing bacteria (**Proteus**, Klebsiella, Pseudomonas, Staph – NOT E.coli) * Alkaline urine pH \> 7 * Tends to fill collecting system “staghorn” * Treatment = complete surgical removal

Answer 69

Cystine stones (hexagon) * Inherited (rr) gene for cystine transport * More soluble at high pH (9.6) = too high, therefore goal is pH \> 7

Answer 70

Prophylactics * All stones = increase urinary volume \> 2 L * Drink 2-3 L of fluid/day (lemonade & OJ – citrate makes urine alkaline) * Reduce salt (\<2g/day) and animal protein (\<6oz/day) * Hypercalciuria = thiazide diuretics (HCTC, chlorthalidone), DO Not restrict calcium intake * Hyperoxaluria = avoid high oxalate foods, moderate calcium diet * Potassium citrate = Increase citraturia and pH, used for hypocitrauric calcium oxalate, uric acid, cysteine stones

Answer 71

Stones \< 4mm likely to spontaneously expel 1. MET shortens duration of stone passage and increases the likelihood of stone passage 1. alpha-blockers and calcium channel blockers in combination with NSAIDs 2. Encourage hydration up to 2L/ day of fluid intake 3. ask the patient to strain their urine to catch and submit their stone for analysis Stones \> 6 mm likely to need intervention 1. Oral Stone Dissolution = Specific to uric acid stones (5-10% of all urinary calculi), can be managed with urine alkalinization with potassium citrate 2. Extracorporeal shock wave lithotripsy (ESWL) 1. External shock waves are concentrated over the area of the stone 2. Many variables at play to determine likelihood of stone clearance, but ideal for stones \<3cm and not in the lower pole 3. Ureteroscopy and Laser Lithotripsy 1. Direct visualization and fragmentation of the stone with a laser 4. Percutaneous Nephrolithotomy = removal of large stones or staghorn calc

Answer 72

1. Patients with recurrent stone episodes and when the patient does not have an obstructing stone 2. 24 hour urine collection for total volume, calcium, oxalate, sodium, uric acid, citrate, phosphate, magnesium, sulfate, & creatinine 3. Serum calcium, phosphorous, uric acid, HC03, BUN, creatinine, albumin, alkaline phosphate, intact PTH (optional), 1, 25-di-OH-vitamin D2 (optional) 4. Stone composition analysis

Answer 73

1. **Colonization =** organisms in urine, but cause no illness/sxs (**asymptomatic bacteriuria**). * Usually not require tx. 2. **Infection (UTI) =** combo of pathogen(s) w/in UT & sxs and/or inflammatory response to pathogen(s) 1. Req tx 3. **Uncomplicated UTI =** infection in healthy patient w/nl anatomically & functionally UT 4. **Complicated UTI =** infection associated w/factors increasing colonization & decreasing efficacy of tx. Requires one or all of following: 1. **Anatomic/functional abnormality** (enlarged prostate, stone disease, diverticulum, neurogenic bladder, indwelling catheter, etc.) 2. **Immunocompromised host** (HIV infection, current chemotherapy, underlying active cancer) 3. **Metabolic disease** (diabetes, renal insufficiency) 4. **Multi-drug resistant bacteria** 5. **Recurrent UTI** = occurs after documented infection had resolved 6. **Reinfection UTI** = a new event w/ reintroduction of bacteria into UT 7. **Persistent UTI** = UTI caused by same bacteria from focus of infection

Answer 74

1. **Periurethral and Urethral Region** = Nl flora contain: lactobacilli, coagulase negative staph, corynebacterium and streptococci =\> barrier against colonization. 1. changes in estrogen, low vaginal pH and cervical IgA affect colonization by normal flora 2. **Urine =** High osmolality, high urea concentration, low pH, high organic acid =\> protective. 1. Glucose in urine may facilitate infections. 2. Tamm Horsfall proteins may be protective. 3. **Bladder =** Epithelium expresses TLRs =\> recognize bacteria =\> initiate immune/inflammatory response (PMNs, neutrophils, macrophages, eosinophils, NK cells, mast cells and dendritic cells). 1. Adaptive immune response then predominantes (T and B lymphocytes). Induced exfoliation of cells also occurs to allow excretion of bacterial colonization. 4. **Kidney =** Local immunoglobulin/antibody synthesis in the kidney occurs in response to infections (IgG, SIgA)

Answer 75

Reduced Urine Flow 1. obstruction (BPH, prostate ca), urethral stricture, foreign body (calculus) 2. neurogenic bladder 3. inadequate fluid uptake Promote Colonization 1. sexual activity – increased inoculation 2. spermicide – increased binding 3. estrogen depletion – increased binding 4. antimicrobial agents – decreased indigenous flora Facilitate Ascent 1. catheterization 2. urinary incontinence 3. fecal incontinence 4. residual urine with ischemia of bladder wall Altered host defense 1. **Obstruction =** increasing susceptibility but does not predispose to infection. 2. **VUR =** VUR =\> UTI =\> renal scarring. 3. **Underlying Disease** = sickle cell disease (SCD), nephrocalcinosis, gout, analgesic abuse, aging, hyperphosphatemia, hypokalemia. 1. **DM**: Glycosuria may contribute to severity of infections due to immune compromise. Majority of infections (80%) are in the upper tracts. 2. **Papillary Necrosis**: due to DM, pyelonephritis, obstruction, analgesics, SCD, transplant rejections, cirrhosis, dehydration, contrast media, renal vein thrombosis. 3. **HIV**: UTIs 5x more prevalent and recur more frequently. 4. **Pregnancy =** 4-7% and incidence of acute clinical pyelo = 25-35% in untreated patients. 5. **Spinal Cord injury** = High Pressure Bladder =\> High morbidity and mortality from bacteriuria.

Answer 76

1. **Escherichia coli** (80% of outpatient UTIs) 1. Uropathogenic E. coli (UPEC) 2. Klebsiella (dinasour) 3. Enterobacter 4. Proteus 5. Pseudomonas (mona) 6. Staphylococcus saprophyticus (5-15%) 7. Enterococcus 8. Candida 9. Adenovirus 10. Normal perineal flora: Lactobacillus, Corynebacteria, Staphylococcus, Streptococcus, anaerobes

Answer 77

Bacterial persistence: complex 1. Infected stones 2. Chronic bacterial prostatitis 3. Fistula disease (colovesical, vesicovaginal) 4. Unilateral infected atrophic kidneys 5. Ureteral duplication and ectopic ureters 6. Foreign bodies (such as retained ureteralstent) 7. Urethral diverticula 8. Unilateral medullary sponge kidneys 9. Infected ureteral stump after nephrectomy 10. Infected urachal or renal cyst 11. Papillary necrosis

Answer 78

HPI 1. May be non-specific for infection 2. Irritative symptoms 1. Frequency, Urgency, Dysuria 2. Hematuria 3. Foul odor, Suprapubic pain 3. Upper tract infections (pyelonephritis) 1. fevers, rigors, flank pain/CVA tenderness, 2. nausea, emesis PE 1. atrophic vaginitis, prostatitis, epididymitis, urethral diverticulum, etc.

Answer 79

Many processes & conditions mimic sxs of UTI; RO other causes prior to tx 1. Urologic neoplasm, Urethral diverticulum, Congenital abnormalities 2. Atrophic vaginitis, Overactive bladder, Interstitial cystitis 3. Prostatitis, Urinary lithiasis 4. STI (Herpes, Chlamydia, Trichomonas, Gonorrhea) 5. Sepsis from non-urologic source 6. Trauma

Answer 80

SPPIN, SNNOUT 1. Clean-catch midstream urine sample 2. Chemical (dipstick) urinalysis 1. **Leukocyte esterase** 63-90% specific 2. **Nitrite** 95% specific gram -, 50% sensitive 3. **Positive Dipstick + sxs** =\> consider tx 4. **Negative Dipstick + sxs** =\> consider culture 3. Urine culture = **\> 10⁵ colonies/ml diagnostic** Further Evaluation 1. **Indications** = anatomic abnormalities/ predispsoing factors OR unresponsive to tx 2. **1st Imaging** 1. US 2. Noncontrast CT 3. Voiding cystourethrogram (VCUG( 4. Abd. & pelvic non-contrast CT 3. **2nd Scopies** 1. Cystoscopic 2. Ureteroscopic

Answer 81

1. Increase fluid intake 2. +/- Topical transvaginal estrogen (atrophic vaginitis) 3. Determine if infection is uncomplicated or complicated

Answer 82

1. 1st line (95% effective) 1. **Trimethoprim/sulfamethoxazole** (TMP/SMX) x 3 days OR 2. **Nitrofurantoin** 100mg BID x 5 days 2. 2nd line = TMP/SMX _resistance_ \> 10% (US west coast, Europe) OR _allergy_ 1. **Fluoroquinolones** (*ciproflo**xacin***, norfloxacin, *oflaxacin*, gemiflorxacin, *levofloxacin*, *moxifloxacin*) 2. **Beta-lactams** **7 day course for (D.PLOP)** 1. DM, 2. Pregnant, 3. Long duration of sxs, 4. Old \> 65 yo, 5. past hx Pyelonephritis

Answer 83

1. Culture essential 2. 1st line 1. Ampicillin + aminoglycoside OR 2. Amp/Vancomycin + aminoglycoside OR 3. 3rd generation cephalosporin (**cef**otaxime, **cef**dinir...) 3. Adjust according to culture results 4. If good clinical response, switch to oral agents in 48 hours 5. Treat for 14 days

Answer 84

1. Acute pyelonephritis w/ intrarenal, perirenal, or pararenal abscess 1. Drainage + complicated UTI 2. Epididymitis 1. **TMP/SMX** or **fluoroquinolones** at least 3 wks 3. Acute bacterial prostatis 1. **TMP/SMX** or **fluoroquinolones** at least 3 wks 4. Chronic bacterial prostatitis 1. **TMP/SMX** or **fluoroquinolones** at 6-12 wks

Answer 85

1. Test of cure = repeat culture in pregnancy, pyelonephritis, and complicated or relapsing UTI. 2. Re-infection = relatively rapid recurrence of UTI w/ same or different organism post cure documentation 1. Each infectious episode should be treated separately. 3. Prophylaxis 1. **[TMP/SMX** (q.d po) OR **nitrofurantoin (**½ daily dose)] x 6 - 12 mos 2. **Single dose abx post-coital** for coitus related recurrent cystitis l

Answer 86

1. Generally, does not require treatment, **except in pregnancy**. 2. Treatment **not** indicated in **elderly** (20 – 40% incidence) and patients on **catheterization** (90% incidence)

Answer 87

1. Relapsing Infection =Failure to clear or completely eradicate the pathogen despite a reasonable treatment course 2. DO urologic investigation that includes imaging to define possible anatomical causes and prolonged therapy in the meantime.

Answer 88

1. Nitrofuranton 2. Fluroquonalones 3. Ampicillin 4. Aminoglycosides 5. Vancomycin 6. 3rd generation cephlorsporin 7. TMX/SMX (not for pseudomonas or enterococcus)

Answer 89

1. **Torsion** = not likely considering onset is over 4-5 days. 2. **Testicular mass** = not tender to palpation. 3. **Fournier’s gangrene** = typically associated w/fever & lethargy; dusky appearance of overlying skin and subcutaneous crepitus. 1. surgical emergency, but very unlikely in this situation. 4. **Scrotal Abscess** = fluctuant 5. **Scrotal cellulitis** = warmth/erythema overlying skin 6. **Epidiymo-orchitis**

Answer 90

1. urgency/frequency, hematuria, dysuria, penile discharge, constitutional symptoms (fatigue, weight loss, fevers, chills), cough. 2. position change (pain better/worse with standing, lifting, raising the scrotum, etc). 3. recent foreign travel. 4. comorbidities (type 1 DM, immune status, history of malignancies). 5. recent sexual activity - 5Ps 1. Partners, Pregnancy prevention, Protection, sexual Practices, PH of STIs

Answer 91

1. **Granuloma inguinale** = painful, beefy red ulcer that bleeds easily 1. Tropics via Klebsiella granulomatosis (intracellular Gram -) 2. Dx = Donovan bodies (rod-shaped organism in cytoplasm of monocytes) 2. **Chancroid** = 1 or more painful genital ulcers +/- tender/suppurative nodes 1. "kissing ulcer" via Haemophilus ducreyi 3. **Lymphogranuloma venereum** = sm genital ulcers resolve =\> inguinal adenopathy =\> Buboes (lg painful LNs) 1. Rectal aquisition via C. trachomatis L1-L3 =\> proctocolitis & colorectal fistulas/strictures (uncommon in USA) 4. **Syphilis** = painless chancre (firm skin ulceration) unless superinfected 1. 2ndary syphilis = nongenital skin lesions (diffuse rash - palms & soles) + adenopathy 2. Latent syphilis = asymptomatic 3. Tertiary syphilis = gummas (soft, granuloma-like lesions) in liver, brain, heart, bones, testis, etc.. associated w/neurologic and cardiac sxs 4. Via spirochete, Treponema pallidum 5. **Genital Herpes** = painful grouped vesicles on erythematous base 6. **HPV** = genital warts 1. HPV 16 & 18 = oncogenic 2. HPV 6 & 11 = low cancer risk 3. Gardasil = against 6, 11, 16, 18

Answer 92

1. Severe infections (abscess, Fournier’s). 2. Increased incidence of malignancies: 1. Kaposi’s sarcoma (possibly involving the genitalia) 2. squamous malignancies of the genitalia 3. testis malignancy (germ cell tumors and lymphomas) 4. renal malignancy.

Answer 93

1. epididymitis, in the setting of STI 2. Empiric tx w/hold imaging as long as there is response to tx 1. TMP/SMX or fluoroquinolones at least 3 wks , 3. If imaging was pursued, a scrotal US be appropriate. 1. It would demonstrate increased blood flow to the epididymis and testis, consistent with inflammation/infection.

Answer 94

1. Nearly 20 million new STIs dx annually 2. highest risk for STIs include: 1. Adolescents and young adults (those aged 15-24 years old account for almost half of all incident STIs). 2. Racial and ethnic minorities. 3. Men who have sex with men (MSM) account for approximately 70% of reported cases of primary and secondary syphyllis, along with more than 50% of HIV positive individuals.

Answer 95

1. **Urethritis =** dysuria, discharge, and pruritis OR asymptomatic 1. Commonly divided into 1. gonococcal = N. gonorrhoeae (mc) 2. non-gonoccal = C. trachomatis, M. genitalium, T. vaginalis, Ureaplasma urealyticum. 2. **Microscopy eval. of urethral discharg**e (swab) = look at a gram stain: 1. gonorrhea urethritis = intracellular gram - diplococci 1. culture in Thayer-Martin 2. non-gonoccal urethritis = wbc w/o bacteria 3. **Nucleic acid amplification testing (NAAT) of urine/body** = test for N. gonorrhoeae or C. trachomatis

Answer 96

1. **Epididymitis/Orchitis =** pain and swelling of testicles, usually unilateral. 1. young men = C. trachomatis (70%) + N. gonorrhoeae (30%) 2. older men = E. coli (not an STI) is the cause of the majority of cases. 3. Chronic infectious epididymitis = granulomatous disease, often Mycobacterium tuberculosis. 2. Proctitis/Proctocolitis = tenesmus (cramping rectal pain), rectal bleeding, abdominal pain, diarrhea, rectal mucus, and pain bowel movements. 1. **N.** **gonorrhoeae****, C. trachomatis** D-K, C. trachomatis L1-L3 (lymphogranuloma venereum), Treponema pallidum (syphilis), and HSV (especially among those with HIV) 2. Additional etiologies = Campylobacter, Shigella, Endamoeba, CMV, and Giardia lamblia.

Answer 97

1. **Cervicitis/vaginitis =** purulent endocervical exudate + sustained endocervical bleeding induced by passage of a cotton swab through the cervical os. 1. **Chlamydia trachomatis + Neisseria gonorrhoeae (most common)** 2. Other 1. **Bacterial vaginosis** (BV, Gardnerella vaginalis) = not STI, but multiple partners cause imbalance in nl flora of vagina and increase risk 2. **Herpes-simplex virus** (HSV) 3. **Trichomoniasis** (Trichomonas vaginalis) = strawberry cervix 4. **Mycoplasma** **genitalium** 3. **Testing** 1. Microscopic eval. of endocervial specimen = BV and Tric) 2. NAAT of urine/fluid = **C.Trachomatis & N.** **gonorrhoeae** 2. **Pelvic Inflammatory Disease (PID)** **sxs** = lower abdominal & pelvic pain, heavy vaginal discharge with odor, dyspareunia, dysuria, and systemic symptoms 1. Dx criteria 1 of the following = pain on cervical motion, uterine or adnexal tenderness 2. High rate of infertility if tx delayed 3. Tx all sex partners in preceding sixty days

Answer 98

Standard treatment for a young man (\<35 yro) with epididymo- orchitis 1. fluoroquinolone x 3 wks 1. However, ciprofloxacin does not reliably cover chlamdyia. 2. Suspect chlamydial infection 1. **azithromycin 1 gm PO once** OR _**doxycycline 100 mg PO twice daily x7 days**._ 3. Empiric Dual therapy (assume co-infection of N. gonorrhoeae) 1. *quinolones are not effective* 2. Administer **3rd generation _cephalosporin**_ _**IM once_** (i.e., **cef**triaxone 250 mg) 4. NSAIDS = analgesic control; the pain may persist longer than infection, secondary to resolving inflammation.

Answer 99

* Untreated infection can lead to PID (the effects of which were previously discussed). * A rare complication of untreated chlamydial infection in men and women: * Reactive Arthritis Syndrome = Triad of urethritis, conjunctivitis, and painless mucocutaneous lesions.

Answer 100

Men who have Unprotected intercourse 1. Screen for Chlamydia & Gonorrhea, HIV & syphilis Screening for Chlamydia annually 1. sexually active women \< 25 yo 2. Women at high risk \> 24 yo

Answer 101

1. Syphilis 2. Gonorrhea 3. Chlamydia 4. Chancroid 5. HIV infection and AIDS 6. Other STIs: reporting requirements vary by state.

Answer 102

1. ectopic ureter from duplicated system can drain into vas deferens/seminal vesicle and predispose to epididymo-orchitis. 2. STI screening (Chlamydia, Gonorrhea, HIV, syphilis) 3. post-void residual (w/ bedside US), to ensure bladder outlet obstruction/urinary retention, is not contributory.

Answer 103

1. Both Lower & Upper Urinary Tract 1. Freq, Urgency, Dysuria, hematuria, irritability, Lethargy, Vomiting, Diarrhea, abdominal distension 2. Lower tract = incontinence, incomplete voding 3. Upepr tract = fever, flank pain (typically intermittent pain and \>39°C) 2. Pyelonephritis and renal abscesses can also result from hematogenous spread (e.g., bacteremia) 3. Fungi = 2nd mc of nosociomial UTI in children, can spread systemically/life-threatening. 1. RF = invasive devices (peripheral and central vascular access lines, drains, and catheters), previous broad-spectrum antibiotic exposure, systemic immunosuppression. 2. Suggestive diagnostic criteria 1. Lack of pyuria & 4\>10 colony forming units/mL (in neonates) from a urine culture obtained by urethral catheterization. 3. kidney mc affected organ in candidiasis, w/“fungus balls” in renal pelvis/calyces, representing a life-threatining 4. US for evaluation of neonates 4. Viral cystitis = Adenovirus types 11 &21, influenza A, polyomavirus BK, HSV =\> voiding sxs, hemorrhagic cystitis & even VUR/retention 1. Self-limiting 2. Only tx if immunocompromised

Answer 104

* After establishing UTI dx, certain children require additional testing to determine causes * eradication of UTI maynot be possible w/ abx alone if there is underlying structural abnormalities. * American Academy Association of Pediatrics UT imaging guidlines * **febrile infant** or **young child 2 mo- 2 yrs** w/ first documented UTI * US abnormal =\> voiding cystourethrogram (VCUG) * **older children** w/ known anatomic structural abnormalities, unusual uropathogens (Proteus/TB), fail to improve w/appropriate antimicrobial therapy, or have an unclear source of infection. * VCUG should be performed as soon as a child is infection-free and bladder irritability has passed, since delaying the VCUG is associated with losing patients to follow-up.

Answer 105

* **Uncomplicated cystitis** via Enterobacteriaceae * **Trimethoprim** (+/- sulfonamide) & **Nitrofurantoin** = effective 96% children * **Abx prophylaxis** = VUR or other structural abn. * leads to higher incidence of organisms such as Enterobacter, Klebsiella, and Proteus

Answer 106

* Ureteropelvic junction (UPJ) obstruction is present in a minority of children born w/hydronephrosis * poor peristalsis of UPJ/anatomic abnormality (stricture/aberrant vessel/high insertion of urter) =\> hematuria, UTI, abdominal mass or pain, nausea, or flank pain which worsens with diuresis (urine production) =\> distension of the renal collecting system (hydronephrosis) * WU * renal ultrasonography * VCUG to rule out CUR (33% of cases) * MAG-3 diuretic renogram look for delayed drainage on affected side * Management = Depends on stability of hydronephrosis, Most req surgical repair * open/laparoscopic pyeloplasty * robot-assisted laparoscopic pyeloplasty

Answer 107

1. ureterocele = cystic dilatation of the terminal, intravesical portion of the ureter 1. 80% ureteroceles drain upper pole of a duplex kidney (two collecting systems) 2. 60% ureteroceles have ectopic orifice in urethra 2. HPI/PE = UTI in first few months of life +/- obstructed upper pole drained by a ureterocele is so hydronephrotic that it is palpable as an abdominal mass. 3. WU 1. US (Dx) = cystic intravesical mass in posterior bladder, dilated proximal ureter, and hydronephrotic/dysplastic upper pole of duplex kidney. 2. VCUG = “drooping lily” sign (lower pole collecting system displaced downward by dilated upper pole) 4. Tx = guided by clinical presentation & kidney function. 1. Infants & children presenting w/urosepsis initially treated with endoscopic incision of the ureterocele to drain it and relieve obstruction. 2. Ureteroceles draining nonfunctioning upper pole moieties can be treated by removal (heminephrectomy and ureterectomy) and the ureterocele itself can be removed through open reconstruction. 3. Functioning units can have their drainage systems reconstructed to promote good drainage as needed.

Answer 108

1. ureteral orifice lies caudal to normal insertion of the ureter on the trigone of the bladder. 2. Most (70%) of ectopic ureters associated w/complete ureteral duplication. In addition, contralateral duplication occurs in 80% of cases. 3. Boys = Ectopic ureters can lie in bladder neck, prostate, or epididymis. 1. UTI or epididymo-orchitis, depending on whether the ectopic orifice is located in the genital ducts. 4. Girls = orifice usually inserts in bladder neck, urethra, vagina, cervix, or uterus. 1. Infant girls = UTI 2. older girls = continuous incontinence bc ureteral orifice is distal to bladder neck. 5. WU 1. US = dilated ureter draining the upper pole kidney of a duplex system. 1. If ectopic ureter drains single system kidney may be dysplastic 2. VCUG = reflux in ectopic system +/- “drooping lily” sign. 3. In girls, ectopic ureters can be diagnosed by placing a cotton ball in the vagina, filling the bladder with dye, and examining the ball for wetness, but absence of dye. 4. MAG-3 study can estimate upper pole function before embarking on surgery. 6. Management determined by presence or absence of ureteral duplication, and kidney function 1. upper pole ectopic segments nonfunctional = removal or redirection ectopic ureter into the urinary drainage system. 2. Ectopic ureters draining single systems 1. reimplanted in the bladder if they drain functional kidneys 2. nephroureterectomy if they drain nonfunctional kidney

Answer 109

1. Hematuria= presence of red blood cells in the urine. 1. Gross = visible by naked eye 2. Microscopic = detected by microscopic examination of urinary sediment. 2. Dipsticks = sensitivity of 95% and specificity of 75% 1. Hematuria = positive results must confirm w/microscopic examination 1. **False +** = **Free hemoglobin, Myoglobin** (obtain serum myoglobin), Certain antiseptic solutions (**povidone- iodine**) 2. **False -** = vit C ingestion, urine pH \<5.1 2. Significant proteinuria (2+ or greater) = nephrologic origin for hematuria. 3. Microscopic examination of urine 1. 10 mL of a midstream, clean-catch specimen centrifuged=\> sediment resuspended 2. **Microscopic hematuria =** \> 3 rbc/hpf on single specimen

Answer 110

S2I3T3 1. Strictures 2. Stones 3. Infection 4. Inflammation 5. Infarction 6. Tumor 7. Trauma 8. TB

Answer 111

1. Glomerular causes = kidney (nephrologist) 1. IgA nephropathy (Berger's disease) 2. Thin glomerular basement membrane disease 3. Hereditary nephritis (Alport's syndrome) 4. Signs 1. red cell casts 2. dysmorphic rbcs 3. significant proteinuria (\>1,000 mg/24 hours) 2. Nonglomerular causes (urologist) 1. upper urinary tract (kidney and ureter) 1. Urolithiasis 2. Pyelonephritis 3. Renal cell cancer 4. Transitional cell carcinoma 5. Urinary obstruction 6. Benign hematuria 2. lower urinary tract (bladder and urethra) 1. Bacterial cystitis (UTI) 2. BPH 3. Strenuous exercise ("marathon runner's hematuria") 4. Transitional cell carcinoma 5. Spurious hematuria (e.g. menses) 6. Instrumentation Benign hematuria (e.g. interstitial cystitis, trigonitis

Answer 112

Micro 1. Older age, Male, Smoking hx, chemical exposure hx, pelvic radiation 2. Weight loss, irritative voding sxs (FUD) 3. Gross hematuria (25%), micro hematuria (3%) Gross 1. Male gender 2. Long term indwelling foley catheter (chronic irritation) 3. Recurrent urinary tract infection (chronic irritation) 4. History of bladder stones (chronic irritation)

Answer 113

1. Cystoscopy 1. microhematuria & 35 yo and older 2. gross hematuria any age 2. Urine cytology or other tumor markers 1. not recommended in asymptomatic microhematuria, but may be considered in patients with risk factors. 3. Delayed excretory cross-sectional abdominal and pelvic imaging is necessary to evaluate the upper urinary tract and exclude upper tract malignancies. 1. CT urography (CTU) = gold standard 1. alt. MR urography or retrograde pyelograms with non-contrasted renal Following an unrevealing work-up for hematuria, a urinalysis should be checked annually. 1. Patients with persistent hematuria after a negative initial evaluation warrant repeat evaluation in 3-5 years, especially in those with risk factors for urologic malignancy.

Answer 114

**Microscopic hematuria =** \> 3 rbc/hpf on single specimen 1. Malignancy (3% chance) (if gross hematuria 25%) 1. Bladder cancer 2. Upper tract urothelial carcinoma 3. Renal cell carcinoma 2. Urolithiasis, BPH 3. UTI, Non-infectious cystitis 4. Glomerulonephritis 5. Trauma 6. Strenuous exercise

Answer 115

1. UA = dipstick, microscopy 2. Lower tract Evaluation 1. Cystoscopy 1. prostate enlargement 2. Ureteral strictures/orfices 3. Lesions/tumors 4. active bleeding 2. Cytology (wash) = "pap smear of bladder" 3. Upper tract Evaluation 1. **CT urogram w/contrast + excretory phase** OR 1. **(MR urography** OR **Retrograde pyelography w/o contrast)** in Cr elevated or Iodone allergy

Answer 116

1. 2 new cases per 100,000 people 1. occur in renal pelvis or ureter 2. RF 1. Tobacco use 2. Cyclophosphamide exposure 3. Phenacetin use 4. Aristolochic acid use 5. Balkan nephropathy 6. Lynch syndrome 7. Chronic inflammation 8. History of bladder cancer

Answer 117

1. HPI = microscopic hematuria 2. WU = UA =\> CT w/contrast post-exposure =\> Ureteroscopy

Answer 118

1. Surgical Management for local (non met) 1. **Gold standard**: radical nephroureterectomy 2. **Nephron-sparing approaches**: case-by-case basis (e.g. tumor location, multifocality, grade, renal function, comorbidities) 1. Partial ureterectomy 2. Endoscopic resection/fulguration 2. Post-op Surviellance 1. Periodic cystoscopy 1. Risk of metachronous bladder cancer: 22-47% 2. Excretory urography of upper tracts (consider surveillance ureteroscopies following nephron-sparing approaches) 1. Risk of metachronous contralateral UTUC: 2-8% 3. Monitor renal function 1. Post nephroureterectomy 2. Post platinum-based chemotherapy (nephrotoxic)

Answer 119

1. Pyridium = Analgesic for UTI sxs 2. Sulfamethoxazole = TMX/SMX "bactrin" abx 3. Nitrofuratoin = Macrobid, Furadantin, Macrodantin abx for UTIs 4. Rifampin = TB abx 5. Ibuprofen = NSAID "advil" 6. Dilantin = Anticonvulsant 7. Levodopa/Methyldopa = tx parkinson 8. Quinine/Chloroquine = Immunosuppressant and anti-parasite (malaria)

Answer 120

1. Hematocrit (compare to last) 2. Creatinine 3. PT, PTT, INR 4. Cytology sent 5. CT Urogram (contrast + delayed study)

Answer 121

1. White males \> 65 yo, \> 80% survive =\> lots of surveillance 2. Urothelial Origin 1. transitional cell carcinoma (95%) = smoking, environmental? 3. Non-urothelial Origin 1. Squamous cell carcinoma (5%) = chronic irritiation & schistosomiasis 2. adenocarcinoma (1%) = bladder exstrosphy (congenital bladder), Urachal cancer 3. SCC, Rhabdomyosarcoma, Pheochromocytoma, Lymphoma 4. 2ndary Malignancy (METS) = melanoma, colon, prostate, lung, breast 5. RF 1. **Environmental** = _Smoking_, chemical exposure (_aniline dyes_, aluminum, paint, petroleum, rubber, textiles), _diet rich with mean & fat._ 2. **Iatrogenic** = Pelvic radiation, Cyclophosphamide (CXT), Chronic cystitis (indwelling catheters) 3. **Geography** = Africa/Middle east à Schistosomiasis (snails)à Squamous cell bladder cancer 4. **Chronic irritation** = (recurrent UTI, bladder stones) 5. Φ familial syndrome

Answer 122

1. HPI/PE 1. 70% **Gross Hematuria** = intermittent, painless 2. 25% Irritable voiding symptoms (urgency, dysuria) ± hematuria 3. Suprapubic, flank, perineal, bone pain in advanced disease

Answer 123

1. **Urine analysis** = Gross exam, dipstick w/micro 1. FISH 2. Asymptomatic microhematuria = ≥ 3 RBCs/HPF in one specimen in absence of obvious benign cause (majority is negative) 3. **Urine culture** = rule out infection 2. **Diagnostic** = image upper & lower tract 1. **CT urogram “Triphasic CT****”** best single study = CT abdomen & pelvis w/contrast 2. **Cystoscopy w/Bx** = **Gold standard-diagnostic**, required to clear bladder (only at urologist) 3. **Urine Cytology** (pap stain) = modest sensitivity, excellent specificity

Answer 124

1. Carcinoma in situ (TIS) = intravesicular chemotherapy 2. Non-muscle invading bladder ca (TIS, Ta, T1) * TURBT + intravesicular chemo (mitomycin C) + BCG (look up dr. o, donell) 3. Muscle invading bladder ca (T2-T4a = lg high grade recurrent lesion) 1. Radical cystectomy (w/PLND & reconstruction) 2. Radiotherapy (if poor surgical candidates) 4. Muscle invading w/ metastases (T4b) = chemo alone 5. Urokinase = urine cotains urokinase, it is an enzyme that promotes clot lysis by converting plasminogen to plasmin

Answer 125

1. **Ischemia** 1. **_Torsion of testis_** "torsion of spermatic cord" 1. Intravaginal = not involve tunica vaginalis 2. Extravaginal (prenatal/neonatal) = involves tunica vaginalis 2. **_Appendiceal torsion_** of testis/epididymis 3. Testicular infarction via vascular insult (cord injury/thrombosis) 2. **_Trauma_** 1. Testicular rupture 2. Intratesticular hematoma, testicular contusion 3. Hematocele 3. **Infectious** 1. **_Acute epidiymititis_** 2. Acute epididymoorchitis 3. Acute orchitis 4. Abscess (intratesticular/intravaginal/scrotal cutaneous cyst) 5. Gangrenous infections (**Fournier's gangrene**) 4. **Inflammatory** 1. Henoch-Schonlein purpura (HSP) vasculitis of scrotal wall 2. Fat necrosis of scrotal wall 5. **_Hernia_** 1. **Incarcerated, strangulated inguinal hernia +/- testicular ischemia** 6. **Acute on chronic events** 1. Spermatocele (epididymal cyst) rupture/hemorrhage 2. Hydrocele rupture/hemorrhage/infection 3. Testicular tumor rupture/hemorrhage/infarct/infection 4. Varicocele

Answer 126

Twisting of testis around spermatic cord =\> bv occulsion =\> ischemia 1. RF 1. Bell Clapper Deformity (intravaginal) = **mc children-_adolesecent_**; consider **40-50 yo too** 2. Neonatal anatomy (extravaginal) = **mc prenatal** \> **postnatal** 2. HPI/PE 1. Sudden acute scrotal/testicular pain & swelling 1. Testicle not lie vertical w/in tunica vaginalis of scrotum 2. Afebrile, no dysuria, normal urinalysis, normal wbc 2. Early (\<12 hrs) = Palpate torsed cord 3. Late (12-24 hrs) = Edema & inflammation (high wbc) 3. Dx = Doppler U/S 1. Arterial flow absent = **torsion** 2. increased flow to epididymis & adenexal structures w/preserved testicular perfusion = **epididymitis** 3. High Sensitivity for testicular trauma, hernia extending into scrotum 4. Low Sensitivity for complex masses above testis 4. URGENT SURGERY/Surgical Exploration 1. Orchiopexy (anchor tunica albuginea to parietal tunical vaginalis & scrotal dartos muscle) 2. w/in 6 hrs of onset = testis salvaged 1. detorse affected testis and perform orchiopexy on BOTH testis (prophylactic) 3. \> 12 hrs of onset = testis atrophy 1. if no perfusion after detorse or hemorrhage/necrotic testis =\> orchiectomy 5. Prevention 1. Intermittent testicular torsion = classic torsion hx but PE & US normal =\> elective bilateral scrotal orchiopexy

Answer 127

Normal Testicle 1. Testicle covered by tunica vaginalis =\> potential space 2. Tunica vaginalis usually attaches to posterior surface of testicles =\> dec. mobility Testicular Torsion 1. Intravaginal testicular torsion = testicle rotate on spermatic cord w/in tunica vaginalis (associated with congenital anomaly "bell clapper deformity" 2. Extravaginal testicular torsion = neonates testes have not dropped =\> tunica vaginalis has not yet attached to testes =\> testicle & tunica vaginalis rotate on spermatic cord.

Answer 128

* Congenital abnormality in 12 % males * uni/bilateral inappropriately high attachment of the tunica vaginalis =\> testicle rotate freely on the spermatic cord within the tunica vaginalis (intravaginal testicular torsion) * Normal testis lie is on the left and the classic “bell clapper” lie is in the middle. The right side shows a bell clapper variation.

Answer 129

small polypoid appendages on testis torse =\> ischemia of appendage 1. RF = remnant Mullerian or Wolffian duct "appendage" 2. HPI/PE 1. Sudden acute scrotal pain & mass 2. testis is palpable w/ normal lie. 3. Early = edematous, palpable at upper pole of testis, +/- ecchymotic =\> "blue-dot sign" on skin 4. Late = difficult to differentiate from testicular torsion or epididymitis due to global enlargement and edema of scrotal compartment 3. Dx = Doppler U/S 1. Normal perfused testis, +/- hypervascularity in area of appendage 4. Tx = Elective exploratory surgery 1. Self limited, infarcted appendage will atrophy w/ time

Answer 130

1. Blunt Trauma =\> testicular rupture, intratesticular hematoma, testicular contusion (bruising) or hematocele (blood collection within the tunica vaginalis space) 1. HPI/PE = Swelling, tenderness or ecchymosis 1. If normal testis on palpation RU rupture 2. if scrotal wall thick w/ edema/hematoma & can't palpate testis =\> US 2. Dx = US 1. **Laceration of tunica albuginea** or **extruded parenchyma** =\> Internal heterogeneity of testis = **testicular rupture** =\> surgical exploration 3. Tx 1. **Testicular rupture** = surgical exploration/rupture - transverse incision 2. **Large or painful hematoceles** = elective drainage. 3. **Intratesticular hematoma** (intact tunica albuginea, localized hematoma) or **local tenderness** (contusion) = observation, rest, cold packs and analgesics 2. Penetration Trauma 1. HPI/PE = usually testicular rupture 2. Dx = scrotal (skin) break 3. Tx = surgical exploration/repair - vertical incision

Answer 131

1. RF 1. \< 35 yo = previous STI, recent sexual activity =\> mc Chlamydia or gonococcal 1. tx = standard antibiotic treatment. 2. Older men = irritative voiding sxs, BPH/incomplete emptying of bladder, or UTI =\> mc enteric gram (-) ascending UTI 2. HPI = gradual, progressive onset pain (mc \> 24 hours) 3. PE = tenderness posterior & lateral to the testis (the usual location of the epididymis). 4. Dx = Doppler US 1. enlarged, hyper vascular epididymis w/ normal or increased blood flow to the testis 2. Abscess formation w/in epididymis/peri- epididymal tissues, can be detected 3. Can't distinguish advanced epididymoorchitis from late torision * both have confluent mass in scrotum w/edema & fixation of the overlying scrotal wall that obliterate normal anatomic landmarks. * Advanced epididymoorchitis =\> compress testicular vasculature =\> ischemia &infarction =\> surgical exploration 5. Tx = epididymitis & orchitis managed conservatively w/antibiotics (broad specturm initially), anti- inflammatory, analgesics, rest and scrotal elevation. 1. If abscess formation = surgical drainage and/or orchiectomy may be necessary

Answer 132

1. medication adverse effects 2. urinary reflux within ejaculatory ducts 3. semen extravasation post vasectomy

Answer 133

1. falcid penile 3 step processe: * a) **smooth muscle relaxation of cavernous arteries** and **trabecular tissue** =\> **increases blood flow** =\> * b) **filling of venous sinusoidal space** w/in corpora cavenosial bodies =\> **lengthens and enlarges penis** =\> * c) **expanded sinusoids compress the subtunical venous plexus** =\> **occlude venous outflow** 2. Full erection = Sensory stimulation triggers the bulbocavernosus reflex =\> ischiocavernosus muscles activation 3. Ejaculation = penile intracavernous pressures reach several hundred mm Hg =\> vascular inflow and outflow temporarily cease 4. Detumescence = sympathetic discharge during ejaculation or degradation of 2nd messengers (cGMP) by phosphodiesterases 5. Nerves 1. **Cavernous nerves** (symp & parasymp) =\> regulate blood flow in corpora cavernosa, corpus spongiosum and glans 2. **Pudendal nerve** (somatic) = penile sensation and contraction/relaxation of the bulbocavernosus & ischiocavernosus muscles that surround the penis. 3. **Endothelium** release Nitric Oxide (MAJOR neurotrasmitter of erection)

Answer 134

1.Failure to initiate (p**sychogenic, neurologic, endocrinologic**), failure to fill (**arteriogenic**), or failure to store (**veno-occlusive dysfunction**) * 10-25% middle-elderly men * “silent marker” for endothelial dysfunction =\> cv disease **2. Mc mixed psychogenic & organic** 1. _Psychogenic_ **=** Performance anxiety, depression, schizophrenia =\> Loss of libido, overinhibition, Impaired NO release 2. _Neurogenic_ = Stroke, Spinal cord injury, Diabetic retinopathy, Parkinson’s, Alzhemier’s =\> Lack of nerve impulse, or Interrupted transmission 3. _Hormonal_ = Hypogonadism, hyperprolactinoma (pituitary tumor) =\> Inadequate nitric oxide release 4. _Vasculogenic_ = **arterial** [atherosclerosis, HTN, DM, hyperlipidemia, smoking, focal stenosis of common penile a. (via sustained blunt perineal trauma)], **venous** [degenerative (Peyronie's disease, aging, DM) or traumatic injury (penile fx)] =\> Impaired arterial flow or veno-occlusive dysfunction 5. _Medication_ = B-blockers, SSRIs, TCAs, diuretics, ROH (large amt), Tobacco =\> Central suppression, Vascular insufficiency 3. RF = **Atherosclerosis, medications, HTN, DM** (compromised sm. vessels affect blood flow & neurotransmitter delivery.), **chronic renal failure**, **heart disease** (psych & vascular), **prostate ca tx** (surgery/radiation), **spinal cord injury** (parasymp mediates erection, symp mediates ejaculation) 4. HPI 1. Psychosocial = chronic issues or acute relationship conflicts optimally treated by mental health professionals. 2. Sexual = Sexual Health Inventory for Men (**SHIM**) assess ED & track response to therapy 3. Medical = **cv disease**, **DM, hyperlipidemia, HTN**, **spinal-cord** **injuy**, pituitary tumor, prostate ca tx (surgical/radiation), **medications** 1. arterial problems = prolonged stimulation required to achieve erection 2. venous leak = erection easily achieved but lost very quickly. 5. PE * Psychologic = **nocturnal/early morning/ situational** **erection** * Neurologic = **abnormal anal tone, lower extremity sensation** * Endocrinologic = **small testes, loss of 2ndary sexual characteristics** (breast, hair distribution) * Vasculogenic = **femoral & pedal pulse** 6. Dx * General = urinalysis, CBC * Vasculogenic = fasting blood glucose, creatinine, +/- cholesterol & TG * Endocrinologic = **Testosterone** & **gonadotropin, prolactin** (elevated prolactin =\> decrease androgen activity) 7. Treatment * psychologic = psychotherapy or sex therapy * hormonal = testosterone (only if pt has low T) * organic = phosphodiesterase-5 (PDE5) inhibitor "sil**_denafil_** (viagra)" =\> prolonged cGMP-mediated smooth muscle relaxation & increase blood flow in corpora cavernosa * refractory to PDE5 = vacuum pumps, intracavernous prostaglandin injections, intraurethral pellet injections, surgical (revascularization, inflatable

Answer 135

1. Life style = healthy lifestyle, stop meds 2. Psychotherapy = patients with chronic/ situational conditions 3. Drugs 1. Phosphodiesterase (PDE) inhibitors = Sildenafil (1st PO for ED) contraindicated w/cv drugs such as nitrate-based drugs (nitroglycerin) & alpha blockers because they can cause sudden hypotension 2. Testosterone = improve libido in men with low testosterone 3. Intracavernosal Injections = papaverine hydrochloride, phentolamine, and alprostadil (a prostaglandin E2) all modulation endothelial function =\> stronger erection. Can cause persistent erection (known as priapism) and scarring. 4. Intraurethral Injections = alprostadil (MUSE) pellet inserted into urethra =\> erection w/in 10 min lasting 30-60 min. Can cause penile pain, warmth/burning in urethra; redness from increased blood flow to the penis; and minor urethral bleeding or spotting. 4. Vacuum Erection Devices = Creates partial vacuum drawing blood into penis. Device made up of cylinder, pump, anelastic band (placed after erection) 5. Penile Surgery 1. Penile prostheses = medication refractory ED. Complications mechanical breakdown, erosion, infection. 2. Reconstruct arteries = young men w/ localized blockage of an artery due to pelvic injury or fracture. 3. Occlude veins that leak = rarely performed due to complexity

Answer 136

Adenocarcinoma of tubular epithelial cells (80-90% all malignant tumors of kidney). Can spread along renal vein to IVC & mets to lung & bone * 3% of american adults, 1/3 die, 1/4 mets @ dx 1. RF 1. **Male** 2. **Life style** = **Smoking, Obesity**, Hypertension 3. **Hereditar**y = Von-Hippel Lindau 4. **Tuberous Sclerosis** = Angiomyolipomas 5. **Acquired renal cystic** disease in patient’s w/end-stage renal disease 2. HPI/PE 1. **classic triad (10%)** = _hematuria_, flank pain, palpable flank mass 2. **Metastatic disease (25%)** = ± Fever, weight loss, **anemia**, cachexia, neuromyopathy 3. ±Paraneoplastic syndrome (eg. Kidney makes the hormones) 1. Hypercalcemia (PTH-related protein): 10% 2. Erythrocytosis (EPO): 5% -10% can lead to polycythemia 3. Hypertension (renin or ACTH) 4. Hepatopathy (Stauffer’s syndrome) = *Reversible* syndrome of hepatic dysfunction (elevated LFTs), Absence of metastatic disease 5. ± Left sided varicocele (if tumor blocks left gonadal vein from emptying into the left renal vein; right gonadal vein empties directly into IVC) 3. Dx 1. US and/or CT to characterize renal mass (usually complex cysts or solid tumor) 2. **Metastatic** = CXR, bone scan if elevated ALP, Head CT/MRI if sxs or widely metastatic disease 4. Tx 1. **Localized** = surgical resection (radical vs. partial nephrectomy) open vs laparoscopic 1. Radical nephrectomy = Reserved for masses “not amenable to partial nephrectomy 2. Partial nephrectomy = Efficacious & safe; Preserves renal function, ↓ long-term morbidity/mortality 2. **Metastatic** = noncurative, cytoreductive nephrectomy followed by immunotherapy 1. CXT & RXT insensitive; Generally poor prognosis

Answer 137

epididymitis extends into the testis and causes testicular tenderness and enlargement

Answer 138

1. Cellulitis 1. Cause = dermatologic (sebaceous cyst, folliculitis) 2. PE = testis is usually palpably normal and nontender, if it can be palpated without compressing the inflamed scrotal wall 3. Tx = Incision & drainage w/gauze packing & broad-spectrum antibiotics 2. Fasciitis of scrotum and groin "**Fournier’s gangrene**" = rapidly progressive, life threatening infection of genital soft tissues. 1. RF = urethral perforation, periurethral abscess, immunocompromised, diabetic patient. 2. PE = diffuse enlargement, thickening and erythema of the scrotal wall, groin and perineum. +/- necrotic black or ecchymotic patches of genital skin present 3. Dx = crepitus, a spongy, cracking feeling within skin indicating gas-producing microbes felt in scrotum or perineum 4. Tx 1. Left untreated = progress over hours =\> bacterial sepsis =\> high mortality rate. 2. broad spectrum antibiotics that cover aerobic & anaerobic organisms, + urgent & repeated surgical drainage & debridement 3. At the time of surgical treatment, cystoscopy and proctoscopy may be performed to exclude urethral and rectal abnormalities.

Answer 139

Incarcerated inguinal hernia = bowel obstruction =\> True surgical emergency 1. RF * heredity, cystic fibrosis, premature birth * Hx of hernias, chronic cough, overweight * being male, pregnant * frequent constipation/standing for long periods of time 2. HPI= sharp pain and swelling of scrotal contents and groin area. 1. Difficult to distinguish incarcerated inguinal hernia from less emergent issues (hydrocele, scrotal trauma, or scrotal abscess) 3. Dx 1. PE exam 2. For less acute hernias "strangulated" imaging prior to surgical exploration = groin & scrotal US or pelvic CT scans 4. Tx = Hernia repairs that use polypropylene mesh for correction may be associated with vas deferens obstruction and infertility later on. 5. Prevention * healthy weight, eat fiber, don't smoke, avoid heavy lifting

Answer 140

1. HPI: testis tumors is chronic in nature, but will present with **acute** **sxs** (pain, swelling, and soreness) if tumor undergo hemorrhage/ necrosis. 2. PE & US = firm, intratesticular mass (\>90% germ cell) 3. Tx = Exploratory surgery - Suspicion of tumor important in acute scrotum, determines approach * **Inguinal** (NOT transcrotal) **orchiectomy** = Removal of one or both testicles and the spermatic cord through an opening in the lower abdomen to minimize tumor spillage/spread.

Answer 141

Heterogeneous group of neoplasms. 95% germ cell (seminomas & Nonseminomas (NSGCT)), virtually all malignant * Seminoma (60%) = respond to radiation tx & chemo * NSGCT = NO radiation tx, some respond to chemo * Teratoma (10%) \> Embryonal \>Choriocarcinoma\>Yolk sac 1. HPI/PE * asymptomatic, unilateral firm mass * most ca b/w 20-34 yo, seminoma b/w 40-50 yo * Cryptorchidism, Klienfelter's syndrome 2. Dx 1. **Scrotal US** (pre OR) 2. CT abd/pelvis & CXR (pre or post orchiectomy) for mets 3. Tumor markers = dx and monitor tx response 1. **B-hCG** = elevated in choriocarcinoma (100%) & seminomas (10%) 2. **a-fetoprotein (AFP)** = elevated in nonseminomatous yolk sac/embryonal. Also in hepatocellular carcinoma, hepatoblastoma, neuroblastoma. NEVER in seminoma 3. **Lactic acid dehydrogenase (LDH)** = tumor burden 4. CBC (anemia), creatinine (AKI, contrast?), LFT 3. Tx 1. **Radical _Inguinal_ orchiectomy** = NO bx due to seeding 2. **Pre orchiectomy Chemo** = met suspicion via labs and imaging 3. **Post orchiectomy** 1. Low stage 1. Adjuvant _Radiation_ therapy = _Seminomas_ 2. Surveillance (CT & tumor markers) = NSGCT 2. High stage 1. Chemo (both seminomas and NSGCT) 1. **Bleomycin** =\> pulmonary fibrosis (↓ pulmonary reserve, ↓ FiO2 (\<25%); avoid fluid overload 2. **Etopside** =\> renal insufficiency (mild), myelosuppression, alopecia, 2ndary leukemia (dose dependent) 3. **Cisplatin** =\> renal insufficiency, N/V, neuropathy, 35% ototoxicity 4. **Ifosfamide** =\> hemorrhagic cystitis; **mesna** is prophylaxis 2. Retroperitoneal lymph node dissection = NSGCT

Answer 142

1. **hydroceles** (increased fluid within the tunical vaginalis space) =\> infection or hemorrhage post trauma =\> acute scrotum sxs 2. **spermatoceles** (cystic dilation of the fine ducts that lead from the rete testis to the epididymal head) =\> infection or hemorrhage post trauma =\> acute sccrotom sxs 3. **Scrotal varicocele** (dilated pampiniform plexus veins surrounding spermatic cord) occurs in 15% of men at puberty and asymptomatic. 1. HPI = acute onset, only right-sided, or persists in supine position, then IVC obstruction must be excluded (i.e., IVC thrombus, abdominal mass, etc.) 2. Dx = history, PE, US sufficient to differntiate benign acute on chronic events 4. Treatment = urgent surgical intervention **rarely** needed for drainage of loculated infection or persistent hemorrhage associated with hydroceles or spermatoceles.

Answer 143

1. Hydrocele & Varicocele 2. Epididymitis & Testicular torsion

Answer 144

1. infection of epididymis, mc from STIs, prostatitis, and/or reflux =\> _Painful scrotal swelling_ 2. HPI/PE * Mc \> 30 yo =\> epididymal tenderness, tender/enlarged testicle(s), fever, scrotal thickening, erythema, and pyuria; + Prehn's sign 3. Dx * UA culture (pyuria) = Gonorrhoea/ Chlamydia (STI), E.coli (reflux) * Doppler US = normal to increase blood flow to testes 4. Tx * Abx = tetracycline, fluroquinolones, NSAIDs), scrotal support for pain

Answer 145

1. twisting of spermatic cord =\> ischemia +/- infarct =\> _Painful scrotal swelling_ 2. HPI/PE * Mc \< 30 yo =\> intense, acute onset scrotal pain, +/- N/V/dizziness, loss of cremasteric reflex; - Prehn's sign 3. Dx * Doppler US = decreased blood flow to testes * If there is high clinical suspicion, skip US and do immediate surgery 4. Tx * attempt manual detorsion * Immediate surgery to salvage testis (usually unsalvagable after 6 hrs of ischemia) * **Orchiopexy** of **both** testis to prevent future torsion

Answer 146

Fluid collection w/in tunica vaginalis 1. Incomplete closure of processes vaginalis (infants) or blockage of lymphatic drainage (adults) =\> fluid filled sac around testis =\> _Painless scrotal swelling_ 2. HPI/PE * asymptomatic; transilluminates (b/c fluid) 3. Dx * US only if concern for inguinal hernia or testicular ca 4. Tx 1. Hernia or Hydrocele persists beyond 12-18 mo of age (increase of inguinal hernias)

Answer 147

1. impaired drainage =\> dilation of pampiniform venous plexus =\> "bag of worms" apperance =\> _Painless scrotal swelling_ 2. HPI/PE * asymptomatic or vague aching scrotal pain * MC left sided, associated w/left-sided renal cell carinoma (b/c left spermatic veins have to go through left renal vein to get to IVC), and infertile men (warm blood near scrotom) * May disappear in supine * NOT transilluminates 3. Dx = US 4. Tx = symptomatic or testis makes up \< 40% total volume 1. surgical = varicocelectomy or ligation 2. IR = embolization

Answer 148

Failure of testicle(s) to descend into scrotum. MC congenital male reproductive abnormality. 1. Low birth weight 2. **Bilateral** is associated w/prematurity, oligospermia, congenital malformation syndrome (Prader-willi, Noonan), infertility. 3. Dx = Testes can’t be manipulated in scrotal sac w/gentle pressure & maybe palpable along inguinal canal or abdomen 4. **Orchiopexy** by 6-12 mo of age (most testes will spontaneously descend by 3 mo) - will not decrease risk of testicular ca 1. **Orchiectomy** if past 12 bc of complications testicular atrophy w/infertility and inc. risk for seminoma

Answer 149

Inflammed testicle 1. Causes 1. Chlamydia trachomatis, Neisseria gonorrheae = Young men (STI =\> UTI =\> reproductive) 2. E coli & Pseudomonas = Older men 3. Mumps virus = (POMP) Pancreatitis, Orchitis (infertility, \>9 yo), Meningitis, Parotid 4. Autoimmune orchitis = Granulomas tubules (ddx = TB) 2. HPI/PE 1. Swelling, pain, tenderness, fever, +/- N/V 3. Dx 1. STI screening = narrow swab inserted into end of penis =\>checked in the laboratory for gonorrhea and chlamydia. 2. Urine test = appearance, concentration or content. 3. U/S Doppler = rule out testicular torsion (less BF), orchitis (higher BF) 4. Nuclear scan of testicles = radioactive tracer is inserted into your bloodstream. The scanner then maps blood flow to your testicles, which can indicate torsion or orchitis. 4. Tx 1. Bacterial = abx 2. Viral = NSAIDs (Advil, Motrin IB, others) or naproxen (Aleve, others), Bed rest & elevation, Cold packs

Answer 150

1. Phimosis = inability of prepuce (foreskin) to retract behind glans penis in uncircumcised males. 1. Benign condition, nearly all boys, but grows out by childhood 2. Adult phimosis (ie, pathologic or true phimosis) via poor hygiene or underlying medical condition (eg, diabetes mellitus). 3. Uncomplicated amenable to conservative medical treatment. 4. Failure of medical treatment warrants surgical intervention (circumcision/ preputioplasty) 2. Paraphimosis = foreskin of uncircumcised/ partially circumcised male is retracted for an extended period of time =\> venous occlusion, edema =\> arterial occlusion =\> foreskin unable to reduce over glans 1. urologic emergency = compromise of arterial flow to glans and constriction can cause gangrene & amputation of glans penis

Answer 151

The cremasteric reflex is a superficial (i.e., close to the skin's surface) reflex observed in human males. This reflex is elicited by lightly stroking or poking the superior and medial (inner) part of the thigh - regardless of the direction of stroke.

Answer 152

deep space in peritoneum that is between rectum and uterus

Answer 153

1. Lower Tract Sxs - UTI 1. acute dysuria, urinary hesitancy, 2. Acute Cystitis = Rarely Fever; urgency, polyuria, and incomplete voids 3. Acute urethritis = Fever may be a component of urethritis-related syndromes (eg, Reiter syndrome, Behçet syndrome); Urethral discharge

Answer 154

Urethral inflammation caused by an STD, either gonococcal urethritis (GU) or nongonococcal urethritis (NGU). 1. HPI 1. Urethral discharge: May be yellow, green, brown, or tinged with blood; production unrelated to sexual activity 2. Dysuria (in men): Usually localized to the meatus or distal penis, worst during the first morning void, and made worse by alcohol consumption; typically not present are urinary frequency and urgency 3. Itching: Sensation of urethral itching or irritation between voids 4. Orchalgia: Heaviness in the male genitals 5. Worsens during menstrual cycle (occasionally). 6. Systemic symptoms (eg, fever, chills, sweats, nausea): Typically absent 2. PE= do not typically present ill or sepsis, primary focus on genitalia 1. Male Exam 1. Inspect the underwear for secretions 2. Penis: skin lesions that indicate STDs (eg, condyloma acuminatum, herpes simplex, syphilis) 3. Urethra: Examine lumen of distal urethral meatus for lesions, stricture, or obvious urethral discharge; palpate along urethra for areas of fluctuance, tenderness, or warmth suggestive of abscess or for firmness suggesting foreign body 4. Testes: mass or inflammation; palpate the spermatic cord; swelling, tenderness, or warmth suggestive of orchitis or epididymitis 5. Lymphatics: Check for inguinal adenopathy 6. Prostate: tenderness or bogginess suggestive of prostatitis 7. Rectal: perianal lesions 2. Women 1. Skin: Assess for lesions that may indicate other STDs 2. Urethra: Strip the urethra for any discharge 3. Pelvis: Complete pelvic examination, including the cervix 3. Diagnosis = based on presence of 1 or more: 1. 1st void urine w/ leukocyte esterase on dipstick test of 10 wbc/hpf 2. urethral smear \>4 leukocytes per oil immersion field 3. mucopurulent urethral discharge 4. Labs 1. Gram stain 2. Endourethral and/or endocervical culture fo**r N** **gonorrhoeae** **and C** **trachomatis** 3. Urinalysis: Not useful test in urethritis, except to rule out cystitis or pyelonephritis 4. Nucleic acid–based tests: For C trachomatis and N gonorrhoeae (urine specimens) and other Chlamydia species (endourethral samples) 5. Nucleic acid amplification tests (eg, PCR for N gonorrhoeae, Chlamydia species) 6. KOH preparation: to evaluate for fungal organisms 7. Wet mount preparation: To detect the movement/presence of Trichomonas 8. STD testing for syphilis serology (VDRL) and HIV serology 9. Nasopharyngeal and/or rectal swabs: For gonorrhea screening in men who have sex with men 10. Pregnancy testing: In women who have had unprotected intercourse 5. Indications to Tx = sxs spontaneously resolve regardless of tx, but tx pts regardless of sxs if .. 1. + gram stain or culture result tx all sexual partners 2. - gram stain and history consistent w/urethritis not likely to return but likely to transmit 6. Treatment - Abx 1. Azithromycin 2. Ceftriaxone 3. Cefixime 4. Ciprofloxacin 5. Ofloxacin 6. Doxycycline 7. Moxifloxacin

Answer 155

Renal tumor of _embryonal origin_ (nonseminomal germ cell tumor) 1. children 2-5 yo, associated w/ 1. **Beckwith-****Wiedemann****syndrome** (hemihypertrophy, macroglossia, visceromegaly) 2. **neurofibromatosis** 3. **WAGR syndrome** (Wilms', Aniridia, Genitourinary abnormalities, mental Retardation) 2. HPI/PE 1. asymptomatic, nontender, smooth abd. mass 2. Abdominal pain, fever, HTN, microscopic/gross hematuria 3. Dx 1. CBC, BUN, Creatinine, UA 2. Abdominal US 3. CT chest & abdomen for mets 4. Tx 1. local resection & nephrectomy w/postsurgical chemotherapy & radition depending on stage & histology

Answer 156

hemihypertrophy, macroglossia, visceromegaly (associated w/ Wilms' tumor in children) * Hemihypertrophy is a genetic disorder characterized by overgrowth of one side of his or her body in. comparison with the other. The overgrowth may affect only one part of the body, such as the legs.

Answer 157

**W**ilms', **A**niridia, **G**enitourinary abnormalities, mental **R**etardation * Wilms' tumor = embryonal origin renal cell tumor in children * **Aniridia** is the absence of the iris, usually involving both eyes. It can be congenital or caused by a penetrant injury

Answer 158

1. Vesicoureteral reflux 2. Ureteropelvic junction obstruction 3. Ureteroceles 4. Ectopic ureters 5. Neuropathic bladder 6. Posterior Urethral valves 7. Eagle-Barrett syndeom 8. Urachal remnants

Answer 159

Also called: penile fibrosis