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Flashcards in 25 - Urology Case Study Deck (78):

Case study 1

A 56 year old male presents to the emergency department with 2 hours of excruciating pain in the right flank and groin radiating into the scrotum

He has had associated nausea and vomiting.
No fever or chills

He had a few twinges of less severe pain over past 2 months

At time of exam he is very anxious, writhing, unable to find comfortable position


Describe the workup of case study 1

Exam: Right costovertebral angle tenderness, Mild RLQ tenderness, Abdomen is not rigid, no guarding or rebound tenderness, No testicular mass or tenderness

Blood work: CBC, BMP normal

UA shows moderate blood with many RBCs, No sign of UTI

Imaging: Noncontrast CT abdomen/pelvis


What is on your differential diagnosis?

- Renal or ureteral stone
- Hydronephrosis (ureteropelvic junction obstruction, sloughed papilla)
- Bacterial cystitis or pyleonephritis
- Acute abdomen (bowel, biliary, pancreas or aortic abdominal aneurysm sources)
- Gynecologic in females(ectopic pregnancy, ovarian cyst torsion or rupture)
- Radicular pain (L1 herpes zoster, sciatica)
- Referred pain (orchitis)


Describe the CT results

- Stone stuck in the ureter
- Kidney is dilated


What are urinary calculi?

- Kidney stones are solutes that occur in amounts too high to stay dissolved (supersaturated) in urine
Solutes precipitate and aggregate to form concretions or stones


What is the most common composition of stones?

Calcium oxalate


What are the other compositions of stones?

From most to least common
- Uric acid
- Struvite (magnesium ammonium phosphate)
- Calcium phosphate
- Cystine


Describe the gold standard imaging protocol for a suspected stone

- CT is best imaging modality to detect urinary calculi. Detects over 96% of stones (study of choice *****)


What are some other imaging options for a stone?

- KUB x-ray may detect 70-80% of stones but may miss smaller calculi. Overlying bowel gas can obscure visualization
- Intravenous urogram (IVU) commonly was utilized prior to wide spread use of CT. Detects up to 80-90% of stones but more time consuming.
- Renal ultrasound (US) can detect most intrarenal stones and hydronephrosis, but not sensitive for ureteral stones. Study of choice for suspected stone in pregnant women


What happens in the first 2 hours of having a renal obstruction

- Increased renal pelvic pressures
- Increased renal blood flow
- As renal pelvic pressure increases, glomerular filtration (GFR) decreases

This back flow pressure and stretching is what hurts like crazy


What happens at 6-24 hours after developing a renal obstruction?

- Renal pelvic pressures remain elevated
- Renal blood flow diminishes


What happens at more than 24 hours after developing a renal obstruction?

- Renal pelvic pressures trend down towards baseline (but remain elevated)
- Renal blood flow continues to diminish.
- If persistent, the obstruction (high grade complete obstruction) leads to renal ischemia and permanent damage typically occurs within 2 weeks


What should you note about this timeline of renal obstruction?

The pattern of pain tends to increase and decrease

The stone will get stuck, cause pain, but then move or rotate and decrease the blockage (incomplete block)


What is the expectant management when trying to allow a stone to pass?

- 2/3 of ureteral stones will pass within 4 weeks of symptom onset
- Complete obstruction is rare so risk of renal deterioration from observation is low
- Strain urine for stone passage
- Medical expusion therapy (Alpha blockers, Calcium channel blockers, NSAIDS)
- Oral stone dissolution (Uric acid stones only, urinary alkalization, potassium citrate, sodium bicarbonate)


What are indications for urgent intervention for urinary stones?

- Obstructed upper tract with infection
- Impending renal deterioration
- Pain refractory to analgesics
- Intractable nausea/vomiting
(Patient preference


What are the surgical stone interventions?

- Extracorporeal Shock Wave Lithotripsy (ESWL)
- Ureteroscopy +/- laser lithotripsy
- Percutaneous Nephrolithotomy (PCNL)
- Open or laparoscopic lithotomy


Describe Extracorporeal Shock Wave Lithotripsy (ESWL)

- 4-15 mm stones in kidney or proximal ureter
- Stone must be radio-opaque


Describe Ureteroscopy +/- laser lithotripsy

All stones amendable but large renal stone treatment is tedious


Describe Percutaneous Nephrolithotomy (PCNL)

- Renal calculi >15-20 mm
- More invasive and requires hospital observation


Describe Open or laparoscopic lithotomy

- Most invasive
- Rarely necessary


How can you prevent stone formation?

- ADEQUATE HYDRATION!! (2.5-3 L/DAY) *******
- Dietary modifications
- Full metabolic evaluation for patients with recurrent stones or strong family history


Describe the dietary modifications

- Low animal protein, low sodium, low oxalate diets
- Normal dietary calcium
- Citrate therapy


Describe the full metabolic evaluation

- Serum chemistries
- 24 hour urine collection
- Medications and additional therapies directed at metabolic abnormalities


Case 2

- A 63-year old male presents with complaint of weak urinary stream, increased urinary urgency, and nocturia x 4.
- He complains he is always tired due to lack of sleep from his nocturia.
- No UTIs or gross hematuria
- No abdominal or flank pain


Describe the work up for case 2

Physical Exam
- Abdomen is soft, nontender, bladder is not palpable
- Phallus is circumcised, no lesions, no testicular mass
- Prostate is moderately enlarged, nontender, symmetric with no nodules

UA shows no blood or infection

PSA 2 (normal


What is on your differential diagnosis at this point?

- Benign prostatic hyperplasia
- Prostatitis
- Overactive bladder
- Prostate cancer
- Bladder cancer
- Urethral stricture
- Bladder or urethral calculus


What are the two types of lower urinary tract symptoms (LUTS)?

- Irritative (storage)
- Obstructive (voiding)


What are the irritative (storage) symptoms?

- Frequency
- Urgency
- Nocturia
- Dysuria


What are the obstructive (voiding) symptoms?

- Hesitancy
- Intermittency
- Straining
- Weak stream
- Terminal dribbling
- Sensation of incomplete bladder emptying


What is the AUA symptom index?

- This shows the IPSS score, also known as the AUA Symptom Score. This is a 7-question survey that patients can often fill out in the waiting room.


What are the items on the AUA symptom index?

- Items = Incomplete emptying, frequency, intermittency, urgency, weak stream, straining, and nocturia


What is the AUA symptom index used for?

- Utilized to determine severity of symptoms (mild, mod, severe), monitor for progression of disease, and monitor response to treatment


Describe how you score the AUA symptom index

Each item scored from 0 (not at all) to 5 (almost always)

Disease Severity Scores
Mild: 0-7
Moderate: 8-19
Severe: 20-35


What is the "big question" on the AUA symptom index?


“If you were to spend the rest of your life with your prostate symptoms just as they are now, how would you feel about that?”

•0 = delighted
•1 = very satisfied
•2 = satisfied
•3 = mixed
•4 = unsatisfied
•5 = unhappy
•6 = terrible

Decision to treat is determined by patient’s level of bother, willingness/ability to comply with therapy, or presence of complications *****


Describe the anatomy of the prostate

18-20 grams in young men

Composed of glandular (70%) and fibromuscular stromal (30%) elements

α-1A receptors predominantly in stroma mediate prostatic smooth muscle tone


Describe the zonal anatomy of the prostate

Zonal Anatomy
- Transition zone—gives rise to BPH
- Central zone
- Peripheral zone—primary zone involved with prostate cancer
- Anterior fibromuscular stroma


Describe the normal prostatic growth pattern

- Testosterone produced by Leydig cells in the tesicles
- Free testosterone is converted to DHT via 5 alpha reductase
- DHT is a more potent androgen than testosterone which binds to prostatic androgen receptors with higher affinity
- DHT stimulates prostate differentiation and growth


Describe the pathophysiology of BPH

- Hyperplasia of glandular and stromal cells in transition zone and periurethral tissue
- Imbalance of cell proliferation and programmed cell death (apoptosis)
- Requires aging and androgens
- Complications and morbidity of BPH due to bladder outlet obstruction (BOO) and associated LUTS
- Severity of symptoms do not


What are the complications of BPH?

- Acute urinary retention
- Renal insufficiency
- Chronic/recurrent UTIs
- Uncontrolled gross hematuria/clot retention
- Bladder calculi


What are the treatment options for BPH

- Watchful waiting
- Pharmacotherapy
- Minimally Invasive Thermal Therapy
- Surgical Options


What are the pharmacotherapy options for BPH?

- α antagonists: relaxes smooth muscle of prostate to alleviate LUTS (most common, quicker response time****)
- 5 α-reductase inhibitors: reduces prostate size over 6-12 months
- Combination therapy: most beneficial men with large prostate and incomplete emptying
- Herbal supplements


Minimally Invasive Thermal Therapy

- TUMT (transurethral microwave therapy)
- TUNA (transurethral needle ablation)
- IL (interstitial laser ablation)


What are the surgical options for BPH?

- Transurethral Surgery (TURP/ laser resection/TUIP)
- Open Prostatectomy


Case 3

78 year old male hospitalized with a non-healing diabetic foot ulcer undergoes partial right foot amputation. Postoperatively he has been unable to void and has developed severe pain.

Prior to admission he had increased urinary urgency/frequency with incontinence and slow dribbling urine stream but felt he emptied his bladder well

He has not had any treatment for bladder or prostate issues in the past


Describe the case 3 work up

- UA shows no blood or signs of infection
- BUN/creatinine mildly elevated but at his baseline (has underlying diabetic nephropathy)
- Abdominal exam: suprapubic distention and tenderness
- GU exam: Prostate enlarged, smooth, nontender on exam, no genital lesions
- Bladder scan shows 900 ml in the urinary bladder


Describe the urinary retention in this patient

- The normal bladder will hold 400-600 ml at capacity.
- Acute distention beyond capacity will cause extreme pain
- Chronic urinary retention of similar volume is often asymptomatic


What are the acute symptoms of urinary retention?

- inability to urinate
- painful, urgent need to urinate
- pain or discomfort in the lower abdomen
- bloating of the lower abdomen


What are the chronic symptoms of urinary retention?

- urinary frequency—urination eight or more times a day
- trouble beginning a urine stream
- a weak or an interrupted urine stream
- an urgent need to urinate with little success when trying to urinate
- feeling the need to urinate after finishing urination
- mild and constant discomfort in the lower abdomen and urinary tract


Describe further testing for case 3

- Physical exam: Bladder/suprapubic pain or distention
- Post void Residual volume measurement (Bladder scan, Straight catheterization)
- Upper urinary tract imaging
- Urodynamics studies
- Cystoscopy


Describe the complications of urinary retention

- Urinary tract infection (UTI)
- Bladder decompensation
- Renal damage


Describe the treatment of urinary retention

Initial bladder drainage with catheterization
- Urethral catheter
- Suprapubic catheter

Treatment of underlying cause


What causes urinary retention?

- Urethral stricture
- Bladder/urethral calculus
- Bladder tumor
- Pelvic organ prolapse
- Extrinsic compression (pelvic mass, fecal impaction)

- Prostatitis
- Vulvovaginitis

- Diabetic cystopathy
- Guillain-Barre syndrome
- Neurologic disease
- Spinal cord injury
- Pelvic trauma
- Childbirth

- Opioid analgesics
- Anesthesia
- Antihistamines
- Decongestants
- Antidepressants



Case 4

- 23 year old woman presents to her doctor complaining of 1 day of increased urinary frequency, dysuria, and sensation of incomplete voiding.
- She says she does not have fever, chills, vaginal discharge, gross hematuria, or flank pain
- She is otherwise healthy, takes no medications
- Sexually active with one partner, no history of sexually transmitted diseases


Describe the physical exam in case 4

- She looks a little uncomfortable but is afebrile with normal vital signs
- Her abdominal exam is notable for mild suprapubic tenderness. No guarding, rebound tenderness or rigidity. No costovertebral tenderness
- Pelvic exam is deferred


Describe the workup of case 4

- Urine dipstick: positive leukocyte esterase, blood and nitrite
- Urinalysis: pyuria (WBC too numerous to count), RBC and bacteria present


What is the diagnosis?



Describe UTIs

- Estimated 150 million UTIs occur world-wide annually
- Accounts for $6 billion in health care expenditures.
- The majority of community- acquired UTIs manifest as uncomplicated bacterial cystitis, and occur mainly in females.
- Approximately 40% of all nosocomial (hospital acquired) infections are UTIs, and most are associated with the use of urinary catheters.
- There are more than 1 million catheter-associated UTIs/year in the U.S


Describe urinary tract bacteria (possible outcomes of culture)

Urine is normally sterile.

Infection (UTI)
- The combination of a pathogen(s) within the urinary system and human host symptoms and/or inflammatory response to the pathogen(s)
- Treatment and management needed.

- Organisms are introduced during collection or processing of urine
- No health care concerns.

- Organisms are present in the urine, but are causing no illness or symptoms (asymptomatic bacteriuria)
- Depending on the circumstances, significance is variable, and the patient may not need treatment.


Describe an uncomplicated UTI

Uncomplicated UTI - infection in a healthy patient with normal GU tract


Describe a complicated UTI

Complicated UTI - infection associated with factors that increase chance of acquiring bacteria and decrease efficacy of therapy.
- Abnormal GU tract (BPH, stone, bladder diverticulum, neurogenic bladder, etc)
- Immunocompromised host
- Multi-drug resistant bacteria


Describe recurrent UTI

Recurrent UTI - occurs after documented infection that had resolved


Describe a reinfection UTI

Reinfection UTI - a new event with reintroduction of bacteria into GU tract


Describe persistent UTI

Persistent UTI - recurrent UTI caused by same bacteria from focus of infection


What are the risk factors for UTI?

- Poor fluid intake/chronic dehydration
- Infrequent voiding
- Incomplete bladder emptying
- Chronic constipation or diarrhea
- Postmenopausal vaginal atrophy
- Staghorn calculi
- Chronic catheterization
- Abnormal urinary tract (obstruction, vesicoureteral reflux, neurogenic bladder)
- Underlying disease (diabetes, immunosuppression)


What are clinical symptoms of cystitis?

Cystitis = bladder/lower urinary tract infection
- Urinary urgency
- Frequency
- Dysuria
- Hematuria
- Foul-smelling urine
- Suprapubic pain
- May have associated urethritis , prostatitis or epididymitis


What are the clinical symptoms of pyelonephritis?

Pyelonephritis = upper urinary tract infections
- Typical symptoms of cystitis
- Fever
- Rigors
- Flank or abdominal pain
- Nausea and vomiting


Describe urine studies that we do

Urine collection
- Midstream clean catch, catheterization, suprapubic aspiration

- Leukocyte esterase
- Nitrite
- Blood, gross or microscopic
>10 WBCs/HPF

Urine culture
- >100,000 colonies/ml


What are the common causative pathogens in adult UTIs?

Common causative pathogen in adult UTIs
- E. Coli (80% of outpatient UTIs)***
- Klebsiella; Enterobacter
- Proteus
- Pseudomonas
- Staphylococcus saprophyticus (5 – 15%)
- Enterococcus
- Candida
- Adenovirus type 11


What are normal perineal flora?

- Lactobacillus
- Corynebacteria
- Staphylococcus
- Streptococcus
- Anaerobes


Describe the treatment of UTI

Empiric antibiotic therapy with sulfamethoxazole/trimethoprim or fluoroquinolones

Adjust antimicrobials based on culture sensitivities for persistent symptoms and complicated/recurrent UTIs

Modify any contributing risk factors

May consider low dose antibiotic suppression for recurrent infections if all modifiable risk factors have been addressed


Case 5

- A 68 year-old man presents with a one week history of intermittent red urine.
- Urine stream a little slow but empies well but denies significant bother.
- He has had no pain or changes in voiding symptoms associated with the change in urine color.
- Cigarette smoker for  20 years.
- On no medications.
- No serious illness in his past.


Case 5 workup

Physical Exam: Healthy appearing male in no acute distress

Abdomen soft, nontender, no mass, no flank tenderness, no genital lesions, prostate mildly enlarged and nontender

UA: large blood, nitrite negative, leukocyte esterase negative

Microscopy: >100 RBC/HPF, 2-5 WBC/HPF


Define hematuria

- Gross hematuria: visible blood in urine
- Microscopic hematuria: > 3 red blood cells per high powered field (RBCs/HPF) a properly collected urine specimen
- May originate from anywhere along the urinary tract


Describe nephrologic or glomerular hematuria

- Significant proteinuria (>1 gm/24 hours)
- Dysmorphic red blood cells
- Red cell casts
- Warrants nephrology evaluation


What are common causes of non-glomerular hematuria?

UPPER urinary tract
- Urolithiasis
- Pyelonephritis
- Renal cell cancer
- Urothelial/Transitional cell carcinoma
- Urinary obstruction
- Benign idiopathic hematuria

LOWER urinary tract
- Bacterial cystitis (UTI)
- Prostatitis
- Benign prostatic hyperplasia
- Strenuous exercise (“marathon runner’s hematuria”)
- Urothelial/Transitional cell carcinoma
- Spurious hematuria (e.g. menses, vaginal atrophy)
- Benign idiopathic hematuria


What are the risk factors for hematuria?


***** History of cigarette smoking ******

- Age >40 years
- Male gender
- History of chemical exposure (cyclophosphamide, benzenes, aromatic amines)
- History of pelvic radiation
- Irritative voiding symptoms (urgency, frequency, dysuria)
- Prior urologic disease or treatment


Describe the hematuria evaluation

- UA with microscopic analysis
- Urine culture (if indicated)
- Urine cytology/tumor markers
- Upper urinary tract imaging (CT urogram is study of choice, other studies include renal ultrasound and intravenous urogram)
- Cystoscopy
- 10-20% of patients evaluated will be diagnosed with a urologic malignancy (HIGH PERCENT ***)


Describe the follow up of hematuria

- Repeat UA with microscopy annually or with any changes in voiding symptoms.
- If patient has UA with no further blood present x 2 may discontinue follow up.
- Patients with persistent hematuria after a negative initial evaluation warrant repeat evaluation at 48-72 months since 3% of this group will be subsequently diagnosed with a urologic malignancy.