Urology

Question 1

A man presents with Left Scrotal dull pain, dragging pain, after sports. PE: (+) cough impulse

Answer 1

Varicocele

Question 2

Imaging of choice for varicocele

Answer 2

Scrotal Doppler

Question 3

Why is varicocele more common in the left?

Answer 3

You have to remember that

1. Left testicular vein drains into the left renal vein in a 90 degree manner
2. Right testicular vein drains into the IVC in an oblique

The slanting of drainage has something to do with pressure and Left Testicular Vein has to drain blood at a much higher pressure

You have to remember that varicocele results from INCOMPETENT VALVES in the testicular vein leading to retrograde blood flow, vessel dilatation and tortuosity of the pampiniform plexus.

Question 4

In which types of scrotal swelling will you be able to go above the swelling on physical examination?

Answer 4

Epididymal Cyst

Hydrocele

Question 5

Acute, severe testicular pain
Common in adolescent and young
Pain does not reduce by elevation of testis

Answer 5

Testicular Torsion

Question 6

Treatment for testicular torsion

Answer 6

Urgent explratory surgery with orchidopexy

Question 7

Dysuria + urethral discharge + sexually active +M fever + red and tender scrotal skin + pain reduced on elevation of testis

Answer 7

Acute EO

Question 8

Common causative agents of EO in a 35 year old sexually-active

Answer 8

Chlamydia

Gonorrhea

Question 9

Common causative agents of EO in >35 y/o

Answer 9

E. coli

Pseudomonas

Question 10

Investigation of choice for acute epididymo-orchitis

Answer 10

Urethral swab and smear

Microscopy and culture of mid-stream urine

Question 11

Treatment of AEO in sexually-active <35 y/o

Answer 11

Cetriaxone 1g IM stat
PLUS
Doxycycline 100mg BD for 10=14 days

Question 12

Acute EO in >35y/o

Answer 12

Ofloxacin 200mg BD x 14 days
OR
Levofloxacin 500mg BD for 10 days

Question 13

Best management for stress incontinence

Answer 13

Pelvic floor exercises

Question 14

Management of renal stones

Answer 14

For a healthy individual:
<0.5 cm - increase oral fluid intake
0.5-2cm - ESWL > Ureteroscopy with dormia basket
>2cm - PCNL

If patient has only ONE FUNCTIONING kidney:
Regardless of the size, Percutaneous nephrostomy

Question 15

FEVER + AKI + STONE + HYDRONEPHROSIS
What does this suggest?
Management?

Answer 15

This suggests OBSTRUCTIVE UROPATHY
Regardless if patient presents with two or one kidney, management is PERCUTANEOUS NEPHROSTOMY to instantly decompress the renal collecting system regardless of the stone size.

***Remember that Percutaneous Nephrostomy is the BEST INITIAL STEP in an attempt to save the kidney. After draining the urine, you may proceed with the most appropriate management by applying the STONE SIZE RULE.

Also, if percutaneous nephrostomy is not available in the options, pick Uretering Stenting as this would function in decompressing the pelvicalyceal system.

Question 16

When is STONE SIZE rule not applicable?

Answer 16

It is not applicable if patient presents with FEVER + ANURIA (AKI) + STONE + HYDRONEPHROSIS. Regardless if the patient has one or two healthy kidneys, patient is managed with percutaneous nephrostomy.

Question 17

Unilateral loin pain + Positive HCG in urine

Answer 17

Suspect Ectopic pregnancy

Question 18

Loin pain + negative HCG + pain radiates to groin
with or without elevated WBCs and CRP
with or without vomiting

Answer 18

Ureteric colic

Question 19

Positive prehn’s signs

Answer 19

Pain relief by elevating the testis

Question 20

Single or multiple cysts that develop slowly + contains clear or opalescent fluid + over 40 years of age + painless, non-tender scrotal swelling + lies above and behind the testis + on examination, usually possible to get above the lump
Diagnosis?
DIagnostic?

Answer 20

Epididymal Cyst

Ultrasound

Question 21

Non-painful, soft, fluctuant scrotal swelling + on examination, possible to get above the lump + contains clear fluid + transilluminates

Answer 21

Hydrocele

Question 22

Severe, sudden onset testicular pain + abnormal testicular lie + affects adolescents and young males + on examination: testicular pain and tenderness not eased by elevation

Answer 22

Testicular torsion

Question 23

How does acute EO present?

Answer 23

Dysuria + urethral discharge + positive prehn’s sign + scrotal skin is red and tender + painful micturition

Question 24

Scrotal swelling typically occurring in the left + dull-aching or dragging pain that is worse after exercise or at the end of the day + bag of worms + show impulse on cough
Management?

Answer 24

Varicocele
If painless - Reassure
If with concerns regarding fertility and if patient complains of persistently severe pain - Surgery

Question 25

Management of testicular malignancy

Answer 25

Orchidectomy via an inguinal approach

Question 26

Management of testicular torsion

Answer 26

URGENT surgical exploration and testicular fixation

Question 27

Urinary urgency or frequency + Subrapubic pain worse on bladder filling and relieved after voiding Diagnostics? Management?

Answer 27

``` Urine (midstream) for culture to rule out UTI Bladder training (Avoid pelvic floor exercises as we need pelvic floor relaxation) ```

Question 28

Leakage of small amount of clear fluid (usually with no distinct odor) into the vagina + history of gyne surgery or radiotherapy (for cervical cancer) Diagnosis? Diagnostic?

Answer 28

Vesicovaginal fistula 3 swab test (3 swabs on top of each other) ***In V-V fistula, you expect discoloration of the topmost or middle swab. Remember that bladder is filled with methylene blue. So if the topmost is wet but no discoloration, fistula must be coming above the bladder which is the ureter, thus, Ureterovaginal fistula should be entertained.

Question 29

Leakage of urine during activity (sneezing, coughing or laughing) Diagnosis? Initial Management?

Answer 29

Stress incontinence Pelvic floor exercises: 8PC TID x 3 mos. If fails, vaginal tape. Duloxetine if not amenable for surgery ***Remember that in stress incontinence, you have weak pelvic floor muscles or bladder outlet that cannot counteract the increased abdominal pressure (during physical activity), hence, leakage of urine.

Question 30

Leakage of urine when there is a sensation of need to void. Diagnosis? Management?

Answer 30

``` Urge incontinence (Detrusor overactivity) Bladder training (anti-M if bladder training fails) ```

Question 31

When I feel the desire to pee, I have to go and pee.

Answer 31

``` Urge incontinence (Detrusor overactivity) Bladder training (anti-M if bladder training fails) ```

Question 32

When I feel a desire to pee, sometimes I slightly wet myself before making it to the bathroom

Answer 32

``` Urge incontinence (Detrusor overactivity) Bladder training (anti-M if bladder training fails) ```

Question 33

DRE finding of BPH

Answer 33

Firm, enlarged, smooth, NOT NODULAR prostate

Question 34

First line treatment of BPH

Answer 34

(Watchful waiting) | Alpha1blocker - Tamsulosin

Question 35

Side effects of Alpha1 Blockers

Answer 35

Postural Hypotension and drowsiness, Cough & dyspnea

Question 36

Finasteride is first-line if patient presents with LUTS with prostate enlargement in addition to this PSA value

Answer 36

> 1.4

Question 37

There is urinary flow obstruction that has been relieved after inserting Foley catheter, what should you do next?

Answer 37

Before jumping into surgery, you must PRESCRIBE TAMSULOSIN and REFER FOR TWOC* *Trial without catheter ***Tamsulosin then TWOC to check if voiding will happen

Question 38

Patient underwent TURP and presents with agitation and confusion. Diagnosis?

Answer 38

TURP syndrome ***Think of dilutional hyponatremia as excessive irrigation might have triggered the dilutional hyponatremia. Excessive irrigation must be done for full visualization.

Question 39

DRE finding of prostate cancer

Answer 39

Hard, asymmetrical, nodular, irregular enlargement with loss of median sulcus

Question 40

HANI of prostate cancer

Answer 40

DRE findings: Hard, asymmetrical, nodular, irregular enlargement of the prostate with loss of median sulcus.

Question 41

First-line investigation if you are presented with a patient who presents with hesitancy, hematuria, weight loss, pain (suprapubic, back, perineal or testicular) with DRE finding of HANI. Most appropriate follow-up investigation?

Answer 41

First-line: Multiparametric MRI | Follow-up: Serum PSA

Question 42

Basing on the PSA levels when do you suspect PSA?

Answer 42

40-49: >2.0 50-69: >3.0 >70: >5.0

Question 43

A known case of prostate cancer presents with LOIN PAIN and ANURIA. RFT is impaired. Diagnostics?

Answer 43

Suspect occluded ureter Do US of KUB

Question 44

A known case of prostate cancer presents with groin/perianal numbness (saddle paresthesia) with back pain and no urge to void

Answer 44

Suspect cauda equina syndrome URGENT MRI of the spine ***Remember SPINE is the most common site of bone metastasis

Question 45

After abdominal surgery, patient presents with unilateral flank pain, anuria post-op. Initial investigation?

Answer 45

Renal ultrasound

Question 46

Why is a patient with sarcoidosis prone in developing kidney stones?

Answer 46

Due to hypercalcemia

Question 47

Most common malignancy in men aged 20-35 years old

Answer 47

Testicular cancer

Question 48

Painless, non-tender lump within the testis + slowly growing + young man Diagnosis? INitial investigation?

Answer 48

``` Testicular cancer (90% is germ cell tumor) Ultrasound | LDH ```

Question 49

Greatest RF for bladder cancer

Answer 49

Smoking

Question 50

Commonest type of bladder cancer

Answer 50

Transitional cell CA

Question 51

Above 40 years old + Frank hematuria | Diagnostics?

Answer 51

Flexible cystoscopy + CT urogram

Question 52

Less than 40 years old with hematuria | Diagnostics?

Answer 52

CT KUB (less likely caused by malignancy

Question 53

After successful treatment of UTI, non-smoker patient aged >45 presents with persistent hematuria. Next step?

Answer 53

Suspect bladder CA even if patient is non-smoker, thus, you should REFER patient for a 2-WEEK WAIT appointment with Uro or Nephro

Question 54

Important disease associated with ADPKD

Answer 54

Intracranial aneurysm

Question 55

Gold standard for Reflux nephropathy

Answer 55

MCUG

Question 56

Diagnostic test of choice to check for renal scarring

Answer 56

Tc scan (DMSA)

Question 57

What is recurrent UTI

Answer 57

2 in 6 OR 3 in 12

Question 58

Description of varicocele with renal pain and hematuria

Answer 58

RCC

Question 59

If a patient is to be requested for PSA, what advice should you give?

Answer 59

Avoid ejaculation or exercise 48 hours before serum PSA test.

Question 60

Isolated frank hematuria in an elderly? Next step?

Answer 60

It is important to rule out bladder cancer, hence, CYSTOSCOPY

Question 61

Prolonged IFC + urine dipstick (+1 protein, 1+ RBC, - nitrates) Best investigation?

Answer 61

Urine culture

Question 62

Investigation for scrotal swelling

Answer 62

Ultrasound

Question 63

A patient presents with LUTS. DRE: large, symmetrical, soft prostate. He was given finasteride. What may be the cause for him being given finasteride? MOA of finasteride?

Answer 63

Elevated PSA > 1.4 | 5-alpha reductase inhibitor

Question 64

Initial investigation for UTI

Answer 64

Dipstick urinalysis

Question 65

DRE finding of acute bacterial prostatitis?

Answer 65

Tender and boggy PG

Question 66

Management for acute bacterial prostatitis?

Answer 66

Empiric antibiotic: Quinolones (ciprofloxacin, ofloxacin)

Question 67

A 55-year old man presents complaining of LBP on urination over the past week. There is also increased urinary frequency. O/E: there is suprapubic tenderness. Per rectal examination detects tender prostate. Midstream urine is sent for culture and sensitivity. What should be done next? What is the likely diagnosis? Next step in management?

Answer 67

Prostatitis | Start on empirical antibiotics - quinolones (No need to wait for culture and sensitivity results)

Question 68

Why do you do cystoscopy and CT urogram in a patient above 40 with hematuria while CT KUB in patients less than 40?

Answer 68

Above 40 with frank hematuria, you rule out bladder cancer through cystoscopy. You also look for ureteric and renal cancers through CT urogram. Since malignancy is not likely to be found in patients below 40, you request for CT-KUB as stone might be the plausible cause of hematuria.

Question 69

Recurrent UTI in postmenopausal women with no other abnormalities?

Answer 69

Vaginal oestrogen ***because of the risk of antibacterial resistance

Question 70

Recurrent UTI in premenopausal women with no other abnormalities

Answer 70

Long-term antibiotic prophylaxis

Question 71

Two conditions where you would pick percutaneous nephrostomy or ureteric stenting

Answer 71

Obstructive uropathy PLUS fever | Obstructive uropathy PLUS AKI

Question 72

Spina bifida with UTI

Answer 72

Urinary incontinence pad

Question 73

Spina bifida with incontinent, no UTI

Answer 73

Self-catheterization

Question 74

Spina bifida with advanced urinary disease

Answer 74

Augmentation cystoplasty and Mitrofanoff stoma