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Flashcards in Urology - Shelf-Life Deck (10):
1

On a routine examination, a 43 year old woman with a history of smoking is found to have microscopic hematuria. She is otherwise asymptomatic. Repeat testing over several months shows persistent microscopic hematuria. Microscopy confirms the presence of isomorphic red blood cells. With the exception of red blood cells present in her urine, the remainder of her testing include complete blood count, urinalysis and renal function are normal. Her physical examination is unremarkable. What is the next step in diagnosis? 

A. Abdominal ultrasound

B. Cystoscopy

C. Observation

D. Renal biopsy

E. Repeat Urinalysis

B. Cystoscopy 

  • Patient has several risk factors for urothelial carcinoma (smoking and age) and should be evaluated with cystoscopy. 
  • Cystoscopy is relatively quick and inexpensive procedure for diagnosing bladder cancer. 

Why are other answers wrong? 

  • An abdominal ultrasound is useful for identifying renal masses, hydronephrosis and bladder masses. 
  • However, urothelial tumours of the upper urinary tract are easily missed. 
  • Thus, it is not the imaging modality of choice for working up hematuria when urothelial carcinoma is suspected. 
  • C is wrong, because this patient has risk factors for urothelial carcinoma. Observation hence would be inappropriate. If continued and exhautive workup fails to identify a source for the hematuria - then observation is appropriate. 
  • Renal biopsy is an invasive test and would be more appropriate if a glomerular source of bleeding was suspected. 
  • At this point, several urinalyses have confirmed microscopic hematuria. Repeating urinalysis would not greatly contributing to finding the cause. 

2

A 67 year old man presents with hematuria and a 10 lb weight loss over the last 8 months. Cystoscopy reveals a large mass on the dome of the bladder. Biopsy of the mass reveals transitional cell carcinoma of the bladder. Which of the following is not a major risk factor for this type of tumour? 

A. Alcohol

B. Dye exposure

C. History of radiation to the pelvis

D. Second hand smoke

E. Smoking

 

A. Alcohol 

  • Urothelial carcinoma of the bladder is the most common type of bladder cancer. 
  • There are numerous risk factors for developing urothelial carcinoma, the most important and common factor being smoking. 
  • Other known risk factors for urothelial carcinoma include (among others) chemical carcinogens (aromatic amines, dyes, occupations working with these chemicals), arsenic, chronic inflammation, human papilloma virus (although primarily associated with squamous cell carcinoma), radiation, cyclophosphamide and phenacetin
  • Although there is some conflicting evidence that excessive alcohol consumption is associated with an increased risk of urothelial carcinoma - it is generally not considered an important risk factor. 

Why are other answers wrong? 

  • Dye exposure and occupations that involve exposure to dyes (hairdressers, barbers, painters) are associated with an increased risk of developing bladder cancer. 
  • Other occupations that are known to have increased risk of developing bladder cancer include metal works, rubber industry workers, miners, cement workers, leather and textile workers and carpet manufactureres. 
  • Multiple studies have shown an increased risk of developing bladder cancer in patients that have received radiation to the pelvis (previous ovarian, cervical, prostate and testicular cancers) 
  • Second hand smoke has been shown to increase the risk of bladder cancer in women up to three fold. 
  • Smoking is the most important risk factor for urothelial carcinoma and is the most important factor contributing to the incidence of bladder cancer in western nations. 
  • Both men and women who smoke have a significant increase in risk .

 

3

A 49 year old woman presents burning during urination and mild back pain not associated with activity. She reports that she has had these symptoms off and on over the last 2 years, but it has been recently been getting worse. Her body temperature is 36.7, blood pressure - 135/85 mmHg, pulse 83bpm and respirations 13/min. On physical examination, there is bilateral mild costovertebral tenderness. The remainder of the physical examination include a pelvic and genitourinary examination is unremarkable. Lab studies and urinalysis reveal:

Leukocytes - 6500/ mm3, Hb - 14.3, Hematocrit - 44.2% and Platelets - 310,000/mm3

pH 7.5, positive for nitrites, negative for protein, glucose, ketones and moderate for leukocytes with traces of blood.

A KUB X-ray was done too, which found opacities which most likely represent material up of which of the following chemical compounds? 

A. Calcium oxalate

B. Calcium phosphate

C. Cystine

D. Magnesium ammonium phosphate

E. Uric acid

D. Magnesium ammonium phosphate 

  • This patient most likely is suffering from bilateral staghorn calculi. The most common component of staghorn calculi stones is struvite (magnesium ammonium phosphate) and calcium carbonate apatite. 
  • The pathogenesis involves infection with urease producing organisms such as Proteus or Klebsiella
  • Infection causes alkalization of the urine and an enviornment in which struvite crystals precipitate. 
  • On microscopy, these crystals appear shaped like a coffin-lid. 
  • Since women are more likely to have upper urinary tract infections, they are also more likely to form staghorn calculi than men. 
  • Patients most frequently present with symptoms of a UTI with mild flank pain and/or hematuria. 
  • If left untreated, staghorn calculi may result in sepsis and kidney failure. 
  • Medical therapy alone is usually not effective; thus surgery is usually recommended. 
  • Percutaneous nephrolithotomy is usually the first-line method of surgical management. 

Why are other answers wrong? 

  • Calcium oxlate is the most common stone composition. They come in two forms, calcium oxalate monohydrate and calcium oxalate dihydrate. Risk factors for formation of this type of stone include:
    • Dehydration
    • Hypercalciuria
    • Hyperoxaluria 
    • Hypernatrituria 
    • Hyperuricosuria
    • Hypocitraturia
    • Excessive ingestion of vitamin D or calcium
    • Sarcoidosis
    • Intestinal bypass surgery 
    • Chronic inflammatory conditions of the bowel
  • On micrscopy the dihydrate crystals appear ''envelope'' shaped while the monohydrate may have a spindle, oval or dumbbell appearance. 
  • Calcium phosphate stones tend to form in alkaline urine such as in patients with renal tubular acidosis
  • Calcium phosphate stones also share some of the risk factors for calcium oxlate including dehydration, hypercalciuria and hypocitraturia 
  • Other causes include chronic ingestion of anatacids. 
  • Cystine stones are associated with the rare genetic disorder cystinuria where patients have a problem with renal cystine transport. 
  • On microscopy, cystine stones appear hexagonal shaped. 
  • Uric acid stones tend to form in conditions with concentrated acidic urine. 
  • Medical conditions associated with uric acid stones include:
    • Diabetes
    • Gout 
    • Lesch-Nyhan syndrome 
    • Chronic diarrhea or dehydration 
    • High protein diet
  • On microscopy, uric acid stones are negatively birefringent with polarization and appear needle shaped. 
  •  

4

A 39 year old white woman presents with chronic complaints of night time frequency, urgency and pelvic pain with intercourse. She has a history of depression and fibromyalgia. Multiple workups including several urinalysis and urine cultures in the past have failed to find a cause for her symptoms. On cystoscopy, several ulcerative patches surrounded by mucuoal edema are seen on the dome of the bladder. A biopsy of the patches reveal mucosal ulceration, chronic inflammatory cells, fibrinous exudate and necrotic debris. Which of the following is the most likely diagnosis? 

A. Bladder Carcinoma

B. Chronic bacterial cystitis

C. Interstitial cystitis

D. Radiation cystitis

E. Somatization disorder

 

C. Interstitial Cystitis 

  • The patient's presentation is most consistent with a diagnos of interstitial cystitis, also called painful bladder syndrome. 
  • The diagnosis one of exclusion. 
  • There are both ulcerative and nonulcerative subtypes of interstitial cystitis. 
  • Biopsy and cystoscopy are often normal. 
  • In many cases, interstitial cystitis is associated with other conditions such as:
    • Depression
    • Anxiety 
    • Irritable bowel syndrome
    • Fibromyalgia
    • Sjogren syndrome 
  • Typically, patients present with suprapubic pain related to bladder filling accompanied by increased frequency. 
  • There must be no urinary infection or other obvious pathology for the diagnosis to be established. 
  • On biopsy, the ulcerative type will classically have Hunner ulcers, which are characterised on cystoscopy as reddened mucosal areas with small vessels radiating toward a central scar accompanied by fibrin deposition, rupture and/or oozing. 
  • Nonulcerative types may have normal appearing epithelium or multiple glomerulations. 

Why are other answers wrong? 

  • On cystoscopy, bladder carcinoma will appear as a solid mass or delicate fronds on the bladder mucosa. 
  • Patients with bladder cancer frequently have hematuria. 
  • However, patients with bladder lesions on cystoscopy are almost always biopsied to rule out cancer. 
  • Microscopically, bladder cancer usually consists of neoplastic and atypical cells. 
  • This patient's cystoscopy and pathologic findings are not consistent with bladder cancer. 
  • Chronic bacterial cystitis can have similar symptoms. 
  • However, there are often white blood cells and blood in the urine and urine culture will usually identify bacteria. 
  • Biopsy may have similar findings with bacteria present. 
  • Radiation cystitis can occur in patients with a history of radiation to the pelvis, such as patients with a history of pelvic tumours. 
  • Cystoscopy findings in radiation cystitis include telengectasias, diffuse erythema, prominent submucosal vascuarlity and mucosal edema. 
  • Biopsy of radiation cystitis will show hemorrhage and hemosiderin, fibrin deposition, acute and chronic inflammation, edema, thickened mucosal folds, vascular ectasias and other changes. 
  • Although chronic pelvic pain can be a feature of somatization disorder, this patient does not meet the criteria for somatization disorder. 
  • Additionally, the cystoscopy is abnormal. Somatization disorder is characterised by the following:
    • history of somatic complaints starting prior to age 30
    • At least four different sites of pain on the body. At least two sites must be gastrointestinal. One must be sexual in nature and another must be pseudoneurologic symptom. 
    • The complaints or symptoms above must not be fully explained by general medical condition or substance abuse. 
    • Complaints must not be feigned. 

5

A 67 year old man presents with significant frequency, excessive dribbling after urination, hesitancy and nocturia. He reports that these symptoms have been progressively getting worse over the last year and are causing him stress. A digital rectal examination (DRE) reveals a diffusely enlarged by soft prostate without nodules or irregularity. Laboratory studies including a urinalysis are unremarkable and a serum prostate-specific antigen is 1.4 ng/mL. Which of the following is the best management for this patient? 

A. Diphenhydramine

B. Observation

C. Prostatectomy

D. Tamulosin

E. Transurethral resection of the prostate 

D. Tamulosin 

  • This patient is presenting with signs and symptoms of modrate benign prostatic hyperplasia (BPH). 
  • This is a common condition in elderly men (over 50) caused by prostate enlargement and progressive slowing or blocking of the urine stream. 
  • Men often present with gradual onset of symptoms such as:
    • frequency
    • weak urine stream
    • leaking/dribbling
    • nocturia 
  • Medications and lifestyle changes are typically the initial management. 
  • There are currently two classes of medications that are used for treating BPH:
    • alpha blockers
    • alpha reductase inhibitors
  • Alpha blockers include medications such as tamulosin and work by relaxing the muscle of the bladder neck. 
  • Alpha-reductase medications include drugs like finasteride. 
  • These medications prevent growth or may even shrink the prostate gland and work best in men with large prostates. 
  • Both classes of drugs may be used in combination. 

Why are the other answers wrong? 

  • Diphenhydramine is an antihistamine that can actually worsen symptoms of BPH. 
  • Medications such as antihistamines and decongestants should be discontinued if possible in men with BPH. 
  • This main is symptomatic with stress from his symptoms. 
  • Observation is not indicated at this time. It may be appropriate in asymptomatic men with BPH
  • Prostatectomy is too invasive to perform on this patient. 
  • Prostatectomies are generally reserved for patients with prostate cancer. 
  • Transurethral resection of the prostate is a surgical treatment that can help with BPH.
  • It is generally used after medical therapy and lifestyle changes have failed to improve symptoms. 

6

A 69 year old man presents with worsening urinary symptoms over the last several years. Reports difficulty urinating. Admits to frequency, dribbling and nocturia. Denies dysuria and hematuria. Past medical history is remarkable for hypertension - takes metoprolol. He smokes 1 pack per day for the last 50 years. He says that his father had prostate cancer, but died shortly after a stroke at age 80. His body temperature is 37.1, blood pressure 135/85 mmH, pulse 85 beats/min and respiratory rate 16. Abdominal and genitourinary examination is normal. Which is the next best step in diagnosis? 

A. Cystoscopy

B. DRE

C. PSA

D. USS

E. Urinalysis

B. DRE

  • This patient is presenting with signs and symptoms of benign prostatic hyperplasia. However, considering his other risk factors, prostate cancer should be ruled out. The initial step in any suspected diagnosis of prostate pathology should be a DRE. 
  • In BPH, the prostate will be diffusely enlarged. In prostate cancer, it will be nodular, firm and irregular. 

Why are the other answers wrong? 

  • Cystoscopy is generally not required in the work-up of BPH. 
  • Although prostate specific antigen measurement would most likely be part of this patient's workup, a DRE should be the initial step in diagnosis. 
  • Ultrasonography is useful for determining bladder and prostate size - along with the presence of hydronephrosis if present. 
  • However, it is generally not considered an essential part of the workup
  • Other tests such as DRE, serum PSA and urinalysis are usually higher yield in the initial workup. 
  • Urinalysis is also part of the initial workup for BPH. 
  • However, DRE is the initial clinical test that should be performed on any patient with symptoms of BPH. 

7

A 55 year old man with a long history of smoking presents for evaluation of a right renal mass found incidentally on imaging after a car accident. He was discharged from the hospital after the accident without any major injuries. He is currently asymptomatic. Magnetic resonance imaging (MRI) is conducted. Laboratory studies show normal renal function. Which of the following is the next best step in management? 

A. Bone scan

B. Computed tomography- guided percutaneous biopsy

C. Nephrectomy

D. Nephrectomy with lymph node dissection

E. Observation

C. Nephrectomy

  • This patient is presenting with a solid renal mass concerning for malignancy as evidenced in the MRI. 
  • Based on the tumour size (greater than 1.5 cm) this tumour has a high probability of being a renal cell carcinoma. 
  • Renal cell carcinoma is most common in men in their 50s or 60s. 
  • Smoking is a major risk factor found incidetally, and it is less comon for patients to present with the classic traid of:
    • hematuria
    • flank pain
    • palpable mass
  • Currently, the best treatment for a solid renal mass is nephrectomy (partial or complete) with pathologic diagnosis after resection. 

Why are other answers wrong? 

  • Bone scans are generally recommended in patients with symptoms of bone metastasis or laboratory evidence of bone involvement such as an elevated alkaline phosphatase. 
  • Percutaneous biopsy of renal cell carcinoma is not recommended due to the high level of false-negative results and high preoperative probability that this mass is a renal cell carcinoma. 
  • Lymph node dissection is generally not performed with localized disease. 
  • There is some recent evidence that extended lymph node dissection may be beneficial in patients with locally advanced disease and/or unfavourable clinical and pathologic characteristics. 
  • Observation may be appropriate for solid renal masses found incidentally that are less than 1.5 cm. 

 

8

A 60 year old man presents with a 2cm fungating mass on his right glans penis that has been growing for the last 6 months. On physical examination, there is left inguinal lymphadenopathy. Biopsy reveals a poorly differentiated squamous cell carcinoma. A partial penectomy is performed and the specimeen sent for a final pathologic diagnosis. Pathologic workup shows clear (greater than 2cm) surgical margins and the tumour invading into the spongiosum. What is the next best management for this patient? 

A. Delayed lymphadenectomy 

B. Immediate bilateral inguinal lymphadenectomy 

C. Immediate left inguinal lymphadenectomy 

D. Observation and close follow up

E. Palliative care

B. Immediate bilateral inguinal lymphadenectomy 

  • This patient has a poorly differentiated penile malignancy. 
  • Unfortunately, patients with poorly differentiated squamous cell carcinoma of the penis that invades into the penile spongiosum or cavernosum (T2) have a high rate of lymph node metastasis (approximately 20%) even with nonpalpable nodes. 
  • Since the lymphatic drainage of the penis has some crossover, contralateral metastasis can occur. 
  • Thus bilateral lymph node dissection is necessary in these patients. 
  • The dissection should be performed as soon as possible since delayed lymphadenectomy is associated with decreased survival. 

Why are other answers wrong? 

  • Delayed lymphadenectomy has been shown to have worse long-term prognosis in patients positive for nodal metastasis. 
  • Although the left nodes will need to be removed, the lymphatic drainage of the penis is to both sides
  • Surveillance has been used with low-grade disease, clear surgical margins, and clinically/radiologically negative nodal metastasis. 
  • The decision to undergo palliative care is reserved for patients with advanced cancer who do not wish to undergo treatment. 

 

9

A 72 year old man complains of back pain and difficulty urinating. A DRE reveals a hard and irregular shaped prostate. Lab studies show a prostate-specific antigen of 19ng/mL. A bone scan of the spine reveals multiple osteoblastic lesions. Which of the following is the next best step in management? 

A. Brachytherapy

B. Androgen deprivation therapy

C. Observation

D. Radical prostatectomy

E. Radiotherapy 

B. Androgen deprivation therapy 

  • This patient is suffering from metastatic prostate cancer. 
  • Since the prostate cancer is not curable - the management typically focuses on relief of symptoms such as this patient's back pain and difficulty urinating. 
  • The initial step is a trial of medical orchiectomy or surgical orchiectomy. 
  • Androgen deprivation therapy is usually recommended as the initial pharmacologic step and can be accomplished with several medications that include gonadotrophin releasing hormone agonist (GnRH) agonists. 

Why are other answers wrong? 

  • Brachytherapy involves ultrasound-guided transperineal placement of radioactive seeds (iodine-125 or palladium-103). 
  • In general, brachytherapy is only recommended for local disease (less than T2a, Gleason score less than 6, and serum PSA less than 10ng/mL).
  • Observation would not be appropriate as this patient is symptomatic and can benefit from treatment. 
  • Radical prostatectomy is the standard therapy for patients with localised disease and survival expectations of greater than 10 years.
  • Radiotherapy may be an option if medical or surgical orchiectomy fails to control this patient's symptoms. 

 

10

A 72 year old man complains of fever, chills, dysuria and pelvic pain that has been present for the last few days. Over the last several hours, he has also had difficulty voiding. His body temperature is 38.3, blood pressure is 130/80, pulse 100 and respiratory rate 18/min. A DRE reveals a tender and boggy prostate. Which of the following is the next best step in diagnosis? 

A. Midstream urinalysis and Gram stain

B. Pelvic CT scan

C. Prostate biopsy 

D. Prostatic message and secretin analysis

E. Prostate specific antigen measurement 

 

 

A. Midstream urinalysis and Gram stain

  • This patient is most likely suffering from acute bacterial prostatitis. 
  • In elderly men, the most common pathogen is infection with E.coli and Klebsiella species. 
  • In younger men, sexually transmitted organisms such as Neisseria or Chlamydia should be suspected. 
  • Acute prostatis usually only occurs with predisposing risk factors such as bladder outlet obstruction or an immunosuppressed state. 
  • Workup for acute bacterial prostatitis includes a midstream urine analysis