Urology

Question 1

Renal colic vs peritonitis

Answer 1

Renal colic - unable to find comfortable position

Peritonitis - movement increases pain, lies still

Question 2

Risk and Presentation of nephrolithiasis

Answer 2

Risk:
Diabetes
Gout
Renal tubular acidosis
Hypercalcemia
Hyperparathyroidism
Family or personal history
Drugs - loops and thiazide diuretics, acetazolamides, topiramate

Presentation:
Acute colicky flank pain radiates to ipsilateral LQ, genital pain
hematuria
N/V
Lower UTI sxs - urgency, frequency, discomfort while voiding

Question 3

Diagnosis and treatment of nephrolithiasis

Answer 3

Imaging:
KUB - radiopaque Stones
CT abd/pelvis - noncontrast stone protocol; most sensitive, can detect uric acid stones
U/S if pregnant
IVP - get scout KUB, give contrast, serial XR

Tx:
Most resolve spontaneously 1-2 weeks

Small stones:
Pain control
Hydration
Urinary strainer - Chemical analysis
Tamsulosin - relaxes smooth muscle in distal ureters to help pass stone
Nifedipine - less commonly used, same mech as above, also impacts BP

Surgical intervention:
\+ fever - risk of sepsis
pain uncontrolled
Unable to pass after several weeks
Elevated creatinine

Question 4

Surgical intervention - nephrolithiasis

Answer 4

Lithotripsy - upper ureter renal collecting system
-must be able to see Stone

ureteroscopy - distal ureter

Percutaneous nephrolithotomy - staghorn or over 3 cm

Question 5

Most common site of renal stone impaction

Answer 5

ureterovesicular junction

Question 6

Hydronephrosis

Answer 6

Dilation of renal pelvis and calyces
Urinary obstruction -> elevated intrarenal pressure
-kidney stones, B/l urgent
-BPH
-cancer
-posterior urethral valves

Presentation:
Usually asx
Vague flank pain
UTI sxs
Anuria

Dx:
r/o obstruction in anurial patient - cath

Tx: underlying obstructions
Ureteral stent
Nephrostomy tube if obstruction is high

Question 7

Calcium oxalate stone

Answer 7

Causes:
Hyper calciuria
Hyperoxaluria
Ethylene glycol ingestion

MC stone type

Question 8

Calcium phosphate stones

Answer 8

Causes:
Hyperparathyroidism
Renal tubular acidosis

Question 9

Cystine stones

Answer 9

Causes: cystinuria

Staghorn calculi
Uncommon - difficult to treat
Hereditary

Question 10

Uric acid stones

Answer 10

radiolucent

Causes:
Gout
Chemo - increase protein metabolism

Can be dissolve by alkalizing urine

• potassium citrate
• sodium bicarbonate
• sodium citrate

Question 11

Struvite stone

Answer 11

Mg-NH4-PO4

UTIs with urease-positive bacteria

• klebsiella
• Proteus mirabilis
• staphylococcus saprophyticus

tend to form staghorn stones

Question 12

Hematuria Causes

Answer 12

Infection, renal stones, trauma
Bladder or renal malignancy - painless, gross hematuria, smoker
Prostate pathology
Endometriosis in GU tract - cyclical
Rheumatic fever, Goodpasture’s syndrome, granulomatosis with polyangiitis, Henoch-Schonlein purpura
Glomerular disease
Sickle cell disease, hemophilia, thrombocytopenia
Simple renal cyst, polycystic kidney disease
Medications - anticoagulants, cyclophosphamide, salicylates, sulfonamides
Exercise-induced

Question 13

Hematuria - dx

Answer 13

gross hematuria - blood is seen - post renal
Microscopic hematuria - more than 3-5 RBC on UA - glomerular

Labs:
UA, urine cytology, 24 hr urine protein, coagulation studies, CBC, BUN/Cr

Imaging: cystoscopy - evaluate for bladder CA
CT/US for stones, cysts, neoplasms

Bx: eval glomerular dz

Treat underlying cause

Question 14

Red urine ddx

Answer 14

rifampin
nitrofurantoin
porphyrins
beets
menses
hematuria - gross

Question 15

Cystitis

Answer 15

Complicated - diabetes, pregnancy, urinary obstruction, immunosuppression, indwelling catheter, abnormal anatomy of GU tract, sxs lasting >7 days, renal failure

Risk factors: female, recent sex, spermicide, hx of UTI

Presentation
Dysuria
Frequency
Urgency
Suprapubic pain
Hematuria - rare

UA: pyruia, bacteria

Bacteria: E. coli (MC), S. saprophyticus, Enterobacter, enterococcus, Proteus, Klebsiella

Tx:
Uncomplicated - nitrofurantoin x5 d, TMP-SMX x 3 d, or fosfomycin single dose

Complicated or pyelo - ciprofloxacin or levofloxacin

Pregnancy: amox, ampicillin, cephalosporins, nitrofurantoin

Question 16

Most common causes of urethritis

Answer 16

Chlamydia trachomatis
Neisseria gonorrhoeae
Mycoplasma
Ureaplasma

Question 17

Urethritis

Answer 17

Presentation:
Dysuria
Urgency
Frequency
Purulent urethral discharge

Dx:
gram stain of discharge
DNA amplification

Tx:
Ceftriaxone IM x1
PO doxy or azythromycin

Treat partners

Complications:
Reinfection of partner
Urethral stricture or scarring
Narrowing of urethral lumen

Question 18

Urge incontinence

Answer 18

leakage of urine associated with strong urge to void

Cause: uninhibited bladder contractions

Dx: r/o UTI

Tx:
darifenacin
fesoterodine
oxybutynin
Solifenacin
Tolterodine
Trospium

S/E: constipation, Blurred vision, dry mouth, cNS/cognitive deficits in elderly

Question 19

Stress incontinence

Answer 19

Leakage of urine during increased abdominal pressure - cough, sneeze, exercise

Risk: obesity, multiparity, female, hx of urethral or prostate surgery in men

Dx: eval for pelvic organ prolapse, urodynamics

Tx:
Kegal exercises
Weight loss
Pessary
Meds: duloxetine
Surgery - midurethral sling

Question 20

Overflow incontinence

Answer 20

Leakage of urine from a overly distended bladder - incomplete emptying

Cause: bladder outlet obstruction (BPH), atonic bladder - spinal injury/disease, DM neuropathy

Presentation:
Constant urinary dribbling
Feeling of incomplete bladder emptying - fullness

Dx:
U/S assess bladder emptying
Cathereterized postvoid residual

Tx:
Decompress bladder with catheter
Address underlying cause

Question 21

Bladder cancer

Answer 21

Transitional cell carcinoma - MC in US

Squamous cell carcinoma - underdeveloped countries, Schistosoma haematobium, chronic irritation (indwelling cath)

Adenocarcinoma - dome, urachial remnant

Risk:
Tobacco
Schistosomiasis
anilin dye or petroleum byproducts
recurrent UTI
M>F
Cyclophosphamide

Presentation:
gross hematuria - painless
Hx smoking
UTI sxs - urgency, frequency, dysuria
Wt loss, fever, palpable suprapubic mass

Dx:
UA: RBCs, cytology
Cytoscopy to visual tumor

Tx: transurethral cytoscopic resection
Radical cystectomy w/ urinary diversion
Rad/chemo if mets

F/U surveillence cystoscopy and intravesicular chemo
If superficial, increased recurrences

Question 22

Varicocele

Answer 22

Dilation of veins in the spermatic cord in the pampiniform plexus in the scrotum

“bag of worms”

Right sided - r/o renal cell carcinoma

Color Doppler ultrasound - retrograde flow to scrotum

Tx: surgery - disrupt dilated vein

Question 23

Hydrocele

Answer 23

Collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis

Will transilluminate

Tx: surgical excision of hydrocele sac if symptomatic

Can occur in infants due to patent processus vaginalis

Question 24

Testicular torsion
Onset
Infection
Visual changes
Support
Cremasteric reflex
U/S
Treatment

Answer 24

Onset - acute, abrupt, and often associated with physical activity
Infection - no signs
Visual changes - raised and horizontal testicle
Support - no change in pain
Cremasteric reflex - absent
U/S - compromise blood flow
Treatment - surgical detorsion w/ b/l orchiopexy within 6 hrs

Question 25

Epididymitis
Onset
Infection
Visual changes
Support
Cremasteric reflex
U/S
Treatment

Answer 25

Onset - subacute and may be associated with STDs and/or anal intercourse
Infection - urethral discharge, fever, dysuria, erythema
Visual changes - normal position
Support - lowers pain
Cremasteric reflex - present
U/S - normal blood flow
Treatment: under 35 - G/C -> ceftriaxone IM + doxy x10 or azithromycin x1
over 35 or h/o anal sex - Enterobacteriaceae -> fluoroquinolone x10-14 day or TMP-SMX

Question 26

Testicular cancer

Answer 26

15-35 yo MC solid cancer
95% germ cell tumors - seminomas, nonseminomatous (embryonal, choriocarcinoma, teratoma, yolk sac young boys)
5% stromal cells tumors - Leydig, Sertoli, granulosa

Risk factors:
Undescended testicle
Prior history of testicular cancer
Family history

Presentation:
Painless, firm testicular mass
Gynecomastia (rare)
sxs of mets - retroperitoneal LN -> mediastinal LN

Labs:
b-hCG - choriocarcinoma, nonseminomatous germ cell tumors
AFP - Embryonal, yolk sac of nonseminomatous
AFP never elevated in Coriocarcinomas or Seminomas
Estrogen - stromal cell tumors

Dx:
Scrotal US
CT of abd/pelvis
CXR
Radial orchiectomy

Tx:
Stage 1 seminoma - radical orchiectomy
Stage 2 seminoma - chemo
Early stage nonseminoma - active surveillance if no risk factors
Later stage nonseminoma - retroperitoneal LN dissection and/or chemo
NO RADIATION

Question 27

Causes of erectile dysfunction

Answer 27

Surgery on prostate or retroperitoneum
Diabetic neuropathy
Vasculogenic - low blood flow, htn, hld, smoking
Hypothyroidism
Hypogonadism
Psych
Drug abuse
heavy alcoholism

Dx: testosterone level, LH, and prolactin
+/- MRI brain

Question 28

Medication is known to cause erectile dysfunction

Answer 28

Most antidepressants - esp SSRIs
Spironolactone
Sympathetic blockers - clonidine, guanethidine, methyldopa
thiazide diuretics (rare)
ketoconazole
cimetidine 
antipsychotics

Question 29

Treatments available for erectile dysfunction

Answer 29

1st line: phosphodiesterase inhibitor - sildenafil, vardenafil, tadalafil

2nd line: penile self injectable drugs - papaverine, phentolamine, alprostadil
-vacuums and constriction devices

3rd line - penile prosthesis implantation
Androgen replacement if hypogonadal

Question 30

Acute prostatitis

Answer 30

Bacterial:
E. coli
Proteus
Klebsiella
Enterobactor
Serratia
Pseudomonas
G/C + urethritis

Presentation:
Fever, chills, myalgias
Frequency, urgency
Rectal pain
Cloudy urine
Pain at the tip of penis

DRE: warm, firm, edematous, tender prostate

Labs: leukocytosis, pyuria, bacteruria, + blood cx, elevated PSA
urine gram stain and cx

Tx: empiric -> sensitivities
TMP-SMX
Fluoroquinolones - cipro, levo

Question 31

chronic pelvic pain syndrome/chronic prostatitis

Answer 31

Presentation:
Pain - perineum, low abd, testicles, back
Difficulty voiding
Sxs >3 mo

Dx: by exclusion

Tx:
Alpha blocker - Tamulosin
Cipro x6 weeks
5 alpha reductase inhibitor (older, not trying for kids)

Question 32

Benign prosthetic hyperplasia

Answer 32

Central zone/transitional zone

Dihydrotestosterone promotes prostate development and growth

Presentation:
Urinary frequency, hesitancy, Decreased urine stream
Terminal dribbling
Nocturia

Treatment:
Alpha-1 adrenergic antagonists
5 alpha reductase inhibitors
Phosphodiesterase 5 inhibitor
Anti-cholinergics
Surgery: transurethral resection of the prostate, plasma vaporization, radiofrequency ablation, Microwave thermotherapy, botox

Question 33

Prostate cancer

Answer 33

Periphery

MC non-dermatologic CA in men - 2nd MC cause of cancer deaths in men

Presentation:
asx
sxs like BPH

DRE: firm nodularity or irregular induration prostate

Labs:
PSA elevated
UA: hematuria, pyuria
Elevated alkaline phosphatase (bone mets)

Dx: bx - adenocarcinoma

Tx:
Radical prostatectomy - risk ED d/t damage of cavernosal nerves, urinary incontinence
Radiation therapy: external beam, brachytherapy (implanted seeds) -> ED, urinary retention/ frequency, urge incontinence
Hormonal therapy - GnRH analog (leuprolide, goserelin) continuously to shut down HPG axis -> decreased testosterone - Chemical castration

Adjuct - flutamide - androgen receptor blocker - less impact on libido and ED

Mets to bone - osteoblastic