Urology

Question 1

Treatment for uncomplicated lower UTI in women

Answer 1

TMP-SMX 160/800 BID x 3 days
Nitrofurantoin ER 100mg BID x 5 days
Cipro 250mg BID x 3 days
Phenazopyridine (pyridium) - bladder analgesic 200 mg

Question 2

Lower UTI tx in pregnancy

Answer 2

Amoxicillin/Ampicillin 250 mg QID x 7 days

Nitrofurantoin ER 100 mg BID x 7 days (1st tri only)

Question 3

recurrent lower uti’s in women

Answer 3

Fosfomycin (Monural) - 6 month trial, post-coital, q 10 day regimen
Base on specific culture results
Trimethoprim (high resist)
Sulfamethaxazole
Nitrofurantoin
1st gen cephalosporins
Fluoroquinolones

Question 4

UTI in men

Answer 4

healthy men - TMP-SMX or fluroquinolone
Complicated - fluroquinolone, first-line
Cipro 500 mg BID x 7-14 days
Levofloxacin 250-500 mg QD x 7-14 days

Question 5

Atypical UTI sx in infants

Answer 5

fevers - most common cause without obvious source
vomiting/diarrhea
failure to thrive
jaundice
irritability

Question 6

causes of acute urethritis or vulvovaginitis 2ndary to irritant

Answer 6

Chemical - bubble baths, soaps
Physical - self-exploration
Biologic - pinworms

Question 7

diagnostic threshholds for UTI by method

Answer 7

Girls clean catch 100,000, repeat if 10,000 to 100,000
Clean catch boys - 10,000
Catheter 10,000, repeat if 1,000 - 10,000
whenever possible get 2 separate samples

Question 8

meds that cause nephritis with resulting hematuria

Answer 8

beta-lactam antibiotics, sulfonamides, NSAIDS, rifampin, cipro, allopurinol, cimetadine, phenytoin

Question 9

causes of hematuria

Answer 9

menstruation, trauma, tumor
kidney stones, cystitis, prostatitis
urethral stricture, glomerulonephritis
foreign body, vasculitis, medication
coagulopathy,

Question 10

work up of hematuria

Answer 10

Met panel, URINE CYTOLOGY, UA with micro and culture

Question 11

enuresis medications

Answer 11

DDAVP (vasopressin)
TCA - imipramine
Anticholinergics - oxybutynin

Question 12

pharm mgt of phimosis

Answer 12

BID topical steroid 6-8 weeks

0. 1% triamcinolone
1. 05% betamethasone

Question 13

paraphimosis intial management, then emergent referral

Answer 13

“squeeze” the edema out, alternate ice application, follow by forceful pushing on the glans with the thumbs while pulling the foreskin with the fingers.

Question 14

balanoposthitis

Answer 14

inflammation of glans and forskin (uncircumsized)
etiology - candida (r/o diabetes)
HSV, HSV, GC, ulcer/syph, psoriasis
poor hygiene - more common in kids

Question 15

balanotinitis w/u

Answer 15

cultures, sti testing, KOH
refer is diagnosis uncertain, symptoms severe,
poor response to tx

Question 16

w/u of BPH

Answer 16

UA, Creatning (may be obstruction), PVR, Urinary flow studies,
How much do symptoms bother patient?
DRE

Question 17

Sx of BPH

Answer 17

incomplete emptying
Frequency <2h
Intermittency
Urgency
Weak Stream
Straining
Nocturia

Question 18

DD of LUTS, ask about

Answer 18

Prostate CA, Bladder CA
UTI
Urethral stricture
Neurogenic bladder (dementia, AZ, MS,CVA, neuropathy)
Bladder calculi
ask about s/sx of diabetes, sexual dysfunction, hematuria, trauma, previous instrumentation, current meds

Question 19

drug therapy for BPH

Answer 19

Alpha 1 adrenergic antagonist (terazosin, tamsulosin (lease BP effect), take at nigh, postural hypotension
5-alpha-reductase inhibitors (finasteride, dutasteride) - long term tx to red. prostate, 6-12 mos, add to alpha antag for severe sx, large prostate >40 gm
Saw palmetto (min. 6 months) anti-inflammatory/ anti-androgenic. 160 mg BID  or 320 mg qd lipophilic extract, take with food

Question 20

treatment for acute prostatitis

Answer 20

admit if severe pain, high fever/rigors, marked leukocytosis, hypotension
OUTPATIENT; Bactrim DS BID, Cipro 500 mg BID, Levofloxacin 500 mg QD x 4-6 weeks
NSAIDS for pain, fever, inflammation.
Start tx then await culture results

Question 21

chronic bacterial prostatitis

Answer 21

prolonged course of abx
Bactrim BID x 8-12 weeks
Cipro 500 mg BID or levofloxacin 500 mg BID x 4 weeks
follow closely after tx
if PARTIAL responsive, use same agent longer or switch and use for 12 weeks
doxycycline 100 mg BID
erythromycin 500 mg QID or
carbenicillin 1g QID
Check post massage urine spec1-2 weeks after therapy

Question 22

abacterial prostatitis, chronic pelvic pain syndrome

Answer 22

not much evidence to support therapies
3 mo trial of alpha blocker
NSAIDS
Heat therapy - sitz back
prostate massage, ejaculation

Question 23

Bell-clapper deformity

Answer 23

affected testis is higher and laterally placed
often early presentation
this and subjective symptoms enough to go to surgery
best if operate with in 6 hours, 50% survival of testes with in 12 h. little testicular survival after 24 hours

Question 24

testicular appendix torsion

Answer 24

blue-dot sign, at upper pole of testes
most common 7-14 y. o.
tenderness limited to upper pole
cemasteric reflex intact
gradual onset of pain
testicular US or color doppler
tx: rest, ice, NSAIDS, surgery not necessary

Question 25

epididymitis sx and tx

Answer 25

acute - rare, associated wth GC/CT, 14-35 y.o, insertive anal I.C.m f/c, irritative voiding with 2ndary UTI, prostatitis or urethritis subacute - more typical, varying degrees of epididymal induration, tenderness, edema, NO irritative voiding, neg. UA, associated with sex, activity, biking, heavy physical exertion. Diagnosis, H and P, GC, chlamydia, UA and C&S, 1st void, +leuk suggests urethritis, r/o torsion color doppler prn to r/o torsion, will show thickened epi and inc blood flow

Question 26

epididymitis tx

Answer 26

acute-->hospitalization subacute-->outpatient, f/u in 3-7 days if <35, treat empirically for GC/CT ceftriaxone once IM 250 mg and Doxy 100 mg BID x 10 days for non-STD ofloxiacin 300 mg BID or levoflaxacin 500 qd x 10 days until culture returns oral analgesia bedrest, support testical, avoid sex or strain, use local heat or cold

Question 27

varicocele

Answer 27

common; 15-20% post-pubertal boys usually left testes, or b/l. if RIGHT-suspect pathological most common correctible cause of infertility dull aching scrotal pain, worse with stand, better recumbent bluish color through scrotal skin testicular atrophy d/t inc temp accentuated by valsalva, decompress when recumbent no clear tx - jock strap/support and NSAIDS

Question 28

epididymal cysts and spermatoceles

Answer 28

``` 2cm epididymal cystic mass superior to testes distinct from testes may transilluminate <2 to 5 cm, rarely symptomatic ```

Question 29

Hydrocele

Answer 29

always transilluminates varying sizes if small, minimal symptoms 'reactive' hydrocele assoc with testicular CA or acute inflammatory scrotal condition (US PRN) treatment rarely indicated, except in infancy

Question 30

Hernias

Answer 30

Inguinal hernias 9:1 male to female Femoral hernia: morei n women Indirect-most common, R>L direct - d/t connective tissue degeneration d/t heavy lifting, straining, wt gain, cough, fat or SI slides through watchful waiting vs. repair, depends on size/symptomatic/worsening/reduceable?, occupation

Question 31

testicular CA

Answer 31

18-40 white, tobacco user, +FH hx of cryptoorchidism or infertility usually painless scrotal heaviness or dull ache (possibly) doesn't transilluminate gynecomastia - ocassionally advanced-mets: abd, neck, lumbar BP, lung (hemoptysis/dyspnea) scrotal ultrasound - if inconclusive, MRI AFP, Beta-HCG, LDH (up if mets) tx: orchiectomy and staging, rad and/or chemo

Question 32

ED

Answer 32

inability 75% of the time older men, stress, chronic disease work up; TSH, LH, electrolytes, glucose, BUN/Cr, testosterone, prolactin, lipids, int. index of Erectile Function

Question 33

PE for ED

Answer 33

eton or nabolic steroid use examin testes look for atrophy, asymmetry or masses femoral and peripheral pulses, ?vasculogenic impotence, pulse quality, bruits visual field defects - pituitary tumors gynecomastia; klinefelter's syndrome (extra x) eval of cremasteric reflex, an index of the thoracolumbar erection center

Question 34

ED MGt

Answer 34

treat/remove cause; meds, tx depression psychological support PDE5 inhibitors, some $$$, levitra now affordable best on empty stomach 1h before intercourse AE: flushing, HA, visual disturbances, dyspepsia, congestion, priapism (uncommon)

Question 35

PDE5 inhibitors

Answer 35

SE; bone/joint/myalgias avoid if on nitrates-severe hypotension caution with alpha blockers

Question 36

hypogonadism

Answer 36

``` causes; testicular dysfunction Hypothalamic-pit dysfunction obesity anabolic steroid use s/sx- anemia, depressed mood, dec. bone density, dim energy, dim vitality, dim muslce mass, impaired cognition, sexual symptoms ```

Question 37

Urge "overactive bladder" vs. stress inc

Answer 37

``` stress-inc with bending, cough, laugh, exercise, small volume inc. urge-can't reach the bathroom in time, leaking, frequent nocturia, frequent daytime urination, urge comes on quickly, large volume incontinence MGT lifestyle/dietary-both behavioral-both pharm-urge electrical stim-urege magnetic stim-stress ```

Question 38

gray zone of PSA

Answer 38

4-10

Question 39

free PSA

Answer 39

``` what portion is unbound by protein, quite reliable those with prostate CA have higher % of bound used for psa levels 4-10 "gray zone" >18% unbound, low risk for prostate CA in a large gland, 14% is cut point PSA density ```

Question 40

who and when to test

Answer 40

start screening at 40-50, stop at life expec < 10 years, nina says 70 hx of first degree relative or AA, esp at young age, less freq PSA if , 2.5 or in their 40s if low risk

Question 41

summary of tx duration for various UTIs in men

Answer 41

``` uncomplicated cystitis; 7 day complicated uti; 7 days + 3-5 days after afebrile pyelonephritis; 10-14 days (oral or IV) Epididymitis; 14 days doxy 50 Acute prostatitis; 30 days Chronic prostatitis; 6 weeks - 3 months ```

Question 42

overactive bladder =

Answer 42

urge/frequency syndrome

Question 43

urethral hypermotility

Answer 43

urethra curls up with coughing

Question 44

voiding diary for adults

Answer 44

24 hour record of voiding, with incontinence episodes, with info about activity and fluid intake 3 normal days include sensations

Question 45

behavioral therapy

Answer 45

inc water, avoid irritants, inc water | bladder training - timed voiding, urge inhibition (bladder distraction)

Question 46

when to try anticholinergics

Answer 46

``` urgency insensible mixed incontinence nocturia for men with BOO, also vie alpha blocker like finasterice (5 alpha reductase inhib) ```

Question 47

anticholinergic agents and SE, action

Answer 47

dry mouth, constipation, confusion in elderly antimuscarinic, anti-spasmodic oxybutinyn (ditropan) tolterodine (detrol)

Question 48

anticholinergics for the elderly

Answer 48

darifenacin trospium fesoterodine

Question 49

some tx options for urge inc

Answer 49

pelvic floor rehab PTNS Botox (watch for retention) sacral neuromodulation

Question 50

tx options for stress inc

Answer 50

surgery | pessary

Question 51

definition of hematuria

Answer 51

>5 per hpf in 3 separate samples is the female menstruating never trust dipstick alone

Question 52

brownish pee with protein or casts

Answer 52

refer to urology

Question 53

peds proteinuria work up

Answer 53

repeat UA x 3 over 1-2 weeks (onlyy if UA is otherwise normal) First am void (r/o orthostatic proteinuria) labs referral

Question 54

if hypospadias and cryptoorchidism present

Answer 54

refer to ped urology, may also need peds endocrinology | may be intersex condition

Question 55

communicating hydrocele mgt

Answer 55

observe until 6 months, then surgery

Question 56

simple hydrocele

Answer 56

observe until age 2

Question 57

varicocele grades and w/u

Answer 57

Grade 1 palpable only when patient is bearing down Grade II palpable w/o bearing down Grade III visible w/o palpation, bag o worms renal u/s for LEFT not reducable and for ALL RIGHT varicoceles refer for any that don't reduce, pain or testicular abnormalities

Question 58

labial adhesion

Answer 58

may get better on their own topical esterase 0.1 BID 4-6 weeks show parent's to put it right at the line once separated, use vaseline so it doesn't readhere

Question 59

causes of scrotal pain

Answer 59

``` testicular torsion epididymitis or orchitis (obtain UA/UC) trauma STI hernia ```

Question 60

tx uncomplicated UTI in kids

Answer 60

``` outpatient oral abx 7-14 days f/u TOC culture, 2-3 days after abx imaging? VCUG/renal US proph abx until imaging? treat dysfunctional elimination ```

Question 61

complicated UTI tx in kids

Answer 61

hospitalization oral/iv abx 10-14 days, PO after 2 days afebrile renal/bladder US if poor clinical response at 48 h VCUG at earliest convenience

Question 62

Peds ABX for UTI

Answer 62

Septra (2 mo and up) r/f jaundice amoxicillin (less than 3 mo) - severe GI SE (doesn't use) augmentin cephalexin cefixime cefpodoxime cipro (20-30 mg/kg/d) complicated, not 1st line kids 0-2 mo, ampicillin + cefotaxime/ceftriaxone (meningitis dose)

Question 63

constipation defined

Answer 63

straining > 25% of the time Hard stools > 25% <3 BM/week palpable mass