Urology

Question 1

pain, redness, and a foul-smelling discharge from under the foreskin of penis

Answer 1

Balanitis

Question 2

Tx of balanitis

Answer 2

Topical antifungal agents: clotrimazole 1% or miconazole 2%, each applied twice daily for one to three weeks

For suspected anaerobic infection: metronidazole 0.75% applied twice daily for seven days
In extreme cases, the foreskin may need to be removed (circumcision)

Question 3

In BPH which area is affected the most

Answer 3

Enlargement of transitional zone;PSA often elevated > 4

Question 4

Tx options of BPH

Answer 4

Relax the bladder/urethra: α-1 blockers - tamsulosin (Flomax)

Decrease prostate size (shrink prostate): 5 alpha-reductase inhibitors (finasteride) and (dutasteride

Question 5

Tx of chlamydia

Answer 5

• CDC recommended treatment for chlamydia is doxycycline 100 mg PO BID × 7 days
  
  • Alternative regimens include: Azithromycin 1 g orally in a single dose OR Levofloxacin 500 mg orally once daily for 7 days

Question 6

Determine cystitis from pylenephritis

Answer 6

• Absence of fever, chills, or flank pain. Change in urine color/odor

Question 7

Cystitis tx

Answer 7

Nitrofurantoin (not over age 65), Bactrim, Fosfomycin

• Ciprofloxacin - reserved for complicated cases
  
  • Postcoital UTI: single-dose TMP-SMX or cephalexin may reduce the frequency of UTI in sexually active women

Question 8

a 25-year-old male with a dull, achy scrotal pain that has been gradually increasing over the last several days. He also reports pain with urination. Physical exam reveals a swollen right testicle with substantial induration. Urinalysis reveals positive leukocyte esterase and 20 WBC/HPF

Answer 8

Epididymitis

Question 9

Epididymitis pathogens based on age (over 35 and under 35)

Answer 9

The pathogen is based on the patient’s age and risk factors:

• men < 35 chlamydia and gonorrhea
• men > 35 E.coli

Question 10

dysuria, unilateral dull aching scrotal pain that can radiate up the ipsilateral flank

Answer 10

Epididymitis

Question 11

Tx of epididymitis in men over 35

Answer 11

• Levofloxacin (Levaquin) 500 mg/day PO for 10 days (21-30 days if associated prostatitis)
• For patients who are unable to take fluoroquinolones, trimethoprim-sulfamethoxazole (one double-strength tablet twice a day for 10 days) is a good alternative

Question 12

Tx of epididymitis under 35

Answer 12

• Doxycycline 100 mg PO BID for 10 days PLUS ceftriaxone 500 mg IM × 1 (or 1 g if the patient weighs 150 kg or greater)
• Refer sexual partner(s) for evaluation and treatment if contact within 60 days of the onset of symptoms

Question 13

inflammation of glomeruli causing protein and RBC leakage into the urine, typically caused by an immune response

Answer 13

Acute glomerulonephritis

Question 14

edema + HTN + hematuria + RBC Casts/dysmorphic RBCs + proteinuria 1-3.5 g/day + azotemia

Answer 14

Nephritic syndrome

Question 15

Urinary excretion of > 3 g of protein in a 24-hour urine sample due to a glomerular disorder plus edema and hypoalbuminemia

Answer 15

Nephrotic syndrome

Question 16

• HTN, azotemia, oliguria (<400 ml urine/day), hematuria (RBC casts) hallmark, edema is not as much as nephrotic syndrome
• Urinalysis: proteinuria < 3.5 grams per day, hematuria, RBC casts

Answer 16

Nephritic syndrome

Question 17

a child with idiopathic nephrotic syndrome improves after treatment with corticosteroids.

Answer 17

Minimal change disease

Question 18

obese patients, heroin, and HIV+ black males.

Answer 18

Focal segmental glomerulosclerosis (FSGS)

Question 19

Passage of intestine through the internal inguinal ring down the inguinal canal, may pass into the scrotum

Answer 19

Indirect inguinal hernia

Question 20

Passage of intestine through the external inguinal ring at Hesselbach triangle, rarely enters the scrotum

Answer 20

Direct inguinal hernia

Question 21

right flank pain radiating into the scrotum, gross hematuria, right-sided hydronephrosis, and normal abdominal x-ray

Answer 21

Nephrolithiasis

Question 22

Nephrolithiasis diagnostic study

Answer 22

• CT scan (spiral CT) without contrast of the abdomen and pelvis is the gold standard for diagnosis
• Urinalysis will often show microscopic hematuria
• BUN and Cr levels (for evaluation of renal function) and also calcium, uric acid, and phosphate levels

Question 23

Four types nephrolithiasis

Answer 23

• Calcium oxalate (80%): Most common, excess oxalate, hyperparathyroidism, radiopaque - avoid grapefruit juice (makes calcium oxalate stones worse)
• Struvite (10%): Associated with chronic UTI with Klebsiella and Proteus species, radiopaque
• Uric Acid (7%): Form in individuals with persistently acidic urine - Excess meat/alcohol, gout, radiolucent
• Cystine (1%): Rare genetic, radiolucent (young boy with kidney stones)

Question 24

Tx for nephrolithiasis

Answer 24

• Analgesia: IV morphine, parenteral NSAIDs (ketorolac)
• Vigorous fluid hydration—beneficial in all forms of nephrolithiasis
• Antibiotics—if UTI is present
• Alpha-blocker therapy (Flomax) for patients with symptomatic ureteral stones >5 mm and ≤10 mm to facilitate ureteral stone passage (usually given to most patients independent of size)

Question 25

**unilateral scrotal swelling with pain** radiating to the ipsilateral groin. Examination reveals a **tender swollen testicle, scrotal edema** with **erythema** and **shininess of the overlying skin.**

Answer 25

Orchitis

Question 26

**inflammation of the testicles**. It can be caused by either **bacteria** or a **virus**

Answer 26

Orchitis

Question 27

MCC of orchitis

Answer 27

* **scending bacterial infection** from urinary tract * Occurs in 25% of postpubertal males with **MUMPS** * **Unilateral** swollen testicle/tenderness with **erythema and shininess** of the **overlying skin,** fever/tachycardia * Orchitis is rarely seen without [**epididymitis**](https://smartypance.com/lessons/infectious-inflammatory-conditions/epididymitis/) unless the patient has mumps

Question 28

Tx of orchitis

Answer 28

If [**mumps**](https://smartypance.com/lessons/viral-disease/mumps/) is the cause, treat mumps (+ ice/analgesia) If **bacteria** is the cause, treat it like [**epididymitis**](https://smartypance.com/lessons/infectious-inflammatory-conditions/epididymitis/) * **Age \<35** or sexually active postpubertal males (cover for GC/Chlamydia) * **Ceftriaxone** 500 mg IM once **PLUS doxycycline** 100 mg PO BID for 10 days * Azithromycin 2 g PO once PLUS doxycycline 100 mg BID if severe PCN allergy * **Age \>35 (STI not suspected) -** **Levofloxacin** 500 mg/d PO once daily for 10 days (21 days if associated [**prostatitis**](https://smartypance.com/lessons/infectious-inflammatory-conditions/prostatitis/))

Question 29

**Ascending infection** of gram-negative rods **into prostatic ducts**

Answer 29

Prostatitis

Question 30

Acute and chronic symptoms of prostatitis

Answer 30

* Acute: sudden onset of **fever, chills,** and **low back pain** combined with **urinary frequency, urgency,** and **dysuria** * Chronic: variable – asymptomatic ⇒ acute symptomatology

Question 31

Prostatitis diagnostics

Answer 31

**Urinalysis** will reveal pyuria and hematuria * **Prostatic fluid** = leukocytosis, culture typically positive for **E.coli** in acute infections * chronic usually have enterococcus * If you suspect acute prostatitis **DO NOT massage the prostate** this can lead to sepsis!

Question 32

Tx of orchitis

Answer 32

* **Men \< 35: Chlamydia** and **Gonorrhea** - **ceftriaxone** and **doxycycline** * **E coli** and **pseudomonas** in **men \> 35** - treat with **fluoroquinolones** or **Bactrim** for **4-6 weeks** to ensure eradication of the infection – culture urine 1 week after the conclusion of therapy

Question 33

Pyelonephritis

Answer 33

Pyelonephritis

Question 34

MCC bug in pyelonephritis

Answer 34

Organism: **E. coli** * Urinalysis: Bacteria and **WBC casts**

Question 35

Tx of pyelonephritis inpt vs outpt

Answer 35

* Outpatient: **FQ (Cipro/Levaquin)/Bactrim** for **1-2 weeks** (longer if immunocompromised) * Inpatient: IV FQ, 3^rd/4^th gen cephalosporins, extended-spectrum penicillins, gentamicin

Question 36

22-year-old male who develops a **firm, painless, non-tender** testicular mass with **elevated serum β-HCG**

Answer 36

Testicular cancer

Question 37

**firm, painless, non-tender** testicular mass and a feeling of heaviness in the scrotum

Answer 37

Testicular cancer sx

Question 38

MC type and RF for testicular cancer

Answer 38

* **Seminoma is the most common type** (60%) * **Risk factors** include **a history of cryptorchidism**

Question 39

Tumor marker of testicular cancer

Answer 39

**AFP, βHCG**

Question 40

Dx of urethritis

Answer 40

**First-void or first-catch urine** and sometimes **urine culture** * **Positive leukocyte esterase** on urine dipstick or having **≥ 10 WBC/HPF** on microscopy is suggestive of urethritis * Diagnosis by culture is not always necessary. If done, diagnosis by culture requires **demonstration of significant bacteriuria** in properly collected urine * **Nucleic acid amplification test** allows for the specific identification of N. gonorrhoeae, C. trachomatis, M genitalium