Final Exam: Urology

What part of the total PSA is helpful in defining risk of prostate cancer when the total PSA is between 4 and 10?

% Free

Risk factors for testicular torsion

-Cryptorchidism -"Bell Clapper" deformity

You suspect your patient has BPH. What is the work up?

-DRE -UA -PSA if approp. -bladder scan -flow rate -PVR urine -cystoscopy -prostate volume measured with TRUS -urodynamics (Low flow rate w/ high pressures = BAD, Atonic Bladder = WORSE)

Overflow Incontinence is caused by:

-Detrusor Underactivity -Outlet Obstruction

What are the side effects of PDE 5 inhibitors?

-HA -flushing -dyspepsia -back pain/myalgia -nasal congestion -abnormal vision -priapism **side effects reduce/resolve with repeated use**

What symptoms are included in the I-PSS (International Prostate Symptom Score) for BPH?

-Incomplete Emptying -Frequency -Intermittency -Urgency -Weak Stream -Straining -Nocturia

What are the two types of testicular torsion?

-Intravaginal -Extravaginal

When is Percutaneous Nephrolithotomy (PCNL) Indicated?

-Stone > 2.5cm -UPJ obstruction -stone in a calyceal diverticulum -failed other therapies

Management of stress incontinence

-Timed Voiding -Kegel exercises -Avoid caffeine -Pessary (if prolapse is present) -Physical therapy -Surgery (sling or urethral bulking)

Workup for prostatitis

-UA with culture -PVR

Prostate cancer is usually asymptomatic unless advanced. What symptoms may be a/w advanced prostate cancer?

-bone pain -hematuria -urinary obstruction

What is the treatment for ischemic low-flow priapism?

-cavernosal aspiration/irrigation -intracavernosal phenylephrine -Sx if above is ineffective

What are the treatment options for Adults with phimosis?

-circumcision -topical steroid cream

If a patient younger than 40 has erectile dysfunction due to a psychogenic component, what is the treatment?

-counseling -ED meds (PDE 5 Inhibitors, etc.)

BPH patients will see a maximal response from Alpha blockers in 1-2 weeks. What side effects can they expect?

-dizziness -fatigue -retrograde ejaculation -orthostatic hypotension -nasal congestion

Anticholinergics are used to treat urge incontinence. Examples: -Oxybutynin -Tolterodine -Solifenacin -Darifenacin -Fesoterodine -Trospium chloride Side effects include:

-dry mouth -constipation -urine retention **caution in elderly secondary to mental status changes**

Classic triad of renal tumors:

-flank mass -hematuria -pain

Nephrolithiasis Treatment if stone is <6mm and there are no fevers, UTI, uncontrolled pain, leukocytosis, or intractable nausea/vomiting:

-increase fluid intake -strain urine -Flomax (increases ureteral peristalsis)

What are the consequences of Cryptorchidism?

-infertility -testicular cancer (Seminoma; most commonly if intraabdominal testes) -torsion

The most common cause of absent testis is ________ or _________ torsion

-intrauterine -perinatal

Bladder cancer presentation

-painless hematuria -irritative sx's If Advanced: flank pain from urinary obstruction, bone pain, and pelvic mass

Testicular cancer presentation

-painless mass -heavy feeling in testicle -back pain if mets -gynecomastia

Extracorporeal Shock Wave Lithotripsy is a non-invasive outpatient therapy that uses sound waves to break the stone via XR technology. What are the contraindications?

-pregnancy -coagulopathy -UTI -obstruction distal to the stone -AAA

Benign Primary renal masses:

-pseudotumors -simple cyst -adenoma -angiomyolipoma -oncocytoma -juxtaglomerular tumor -multilocular cystic nephroma -mesoblastic nephroma

Malignant Primary renal masses:

-renal cell carcinoma -Wilm's tumor -clear cell sarcoma -rhabdoid tumor -leiomyosarcoma

What are the causes of ischemic low-flow priapism?

-sickle cell trait or disease -malignant infiltration of the corpora -TPN -trazadone -cocaine -phenothiazines -tx for ED (iatrogenic)

What are the risk factors for Renal Cell Carcinoma?

-smoking -VHL -tuberous sclerosis -FHx -horseshoe kidney -acquired polycystic kidney disease -obesity -diuretics (overuse)

What are the indications for a PARTIAL nephrectomy in a patient with renal cell carcinoma?

-solitary kidney -bilateral tumors -poor renal function -contralateral kidney is threatened by disease -elective

What are the two primary considerations that determine treatment of kidney stones?

-stone size -stone location

Risk Factors for testicular cancer:

-undescended testicle (MC on right side) -HIV -gonadal dysgenesis and testicular feminization

Testicular cancer pathology by age: 0-10 y/o = 20-30 y/o = 25-35 y/o = 30-40 y/o = >50 y/o =

0-10 y/o = yolk sac 20-30 y/o =choriocarcinoma 25-35 y/o = embryonal, teratoma 30-40 y/o =classic seminoma >50 y/o = malignant lymphoma

Age Appropriate PSA 40-49 = 0-2.5 50-59 = 0-3.5 60-69 = 0-4.5 70-79 = 0-6.5 Don't need to memorize, but just know that in general, the normal range of PSA is _____-_____ and know that PSA naturally increases with age.

0-4

PSA increase of more than _____ ng/ml/year, suggests prostate cancer

0.75

What are the types of priapism

1. Ischemic-low flow (most common) 2. Non-ischemic-high flow

From most common to least common, list the sites of metastatic renal cell carcinoma:

1. lung (most) 2. bone 3. regional nodes 4. liver 5. adrenal (ipsilateral) 6. kidney (contralateral) 7. brain (least)

From most common to least common, list the sites of metastatic Wilm's Tumor in children:

1. lung (most) 2. liver 3. bone 4. brain

HIgh grade microscopic hematuria is more than _______ RBC's/hpf

100

Microscopic Hematuria is defined as the presence of greater than _____ RBC on at least 2 of 3 clean catch UA's or freshly catheterized specimen.

3

How do we calculate PSA velocity?

3 PSA readings taken at least 6 months apart

Varicocele Repair can be open, laparascopic, robotic or through percutaneous embolization. Repair improves semen quality in 70% of men and appears to improve fertility. Time to improvement of semen quality is ____-____ months

3-6

Priapism is an erection lasting longer than _____ hours and can result in compartment syndrome

4

Epididymitis is inflammation of the epididymis, which is responsible for storage, maturation and transport of semen. After age _________, epididymitis is commonly seen in conjunction with structural abnormalities of the urinary tract

40

Men with longer than 10 years to live should be screened for prostate cancer at age 50+. If high-risk, african american, or family history of prostate cancer, they should begin screening at age ____-_____.

40-45

______________ block the conversion of testosterone (T) to dihydrotestosterone (DHT) which can result in a 25% reduction in prostate size and a 50% reduction in PSA after 6 months of treatment. Exceptions: •Not helpful if prostate size is less than 40cc

5 alpha reductase inhibitors •Dutasteride (Avodart) •Finasteride (Proscar, Propecia) Side effects are uncommon: -ED -decreased libido -gynecomastia

The greatest benefit of screening appears to be in men ages ____ to ____ years. (yearly PSA and DRE)

55 to 69

Chronic epididymitis is characterized by epididymal pain and inflammation that lasts more than _____ weeks and may be accompanied by scrotal induration

6

PSA Density of _________ suggests prostate cancer i.e. larger glands make more PSA!

>0.15

What race has the higher baseline PSA?

African Americans

What is the first line treatment for BPH?

Alpha Blockers -Tamsulosin (Flomax) -Alfuzosin (Uroxatral) -Silodosin (Rapaflo) -Terazosin (Hytrin) -Doxasosin (Cardura) *Tamsulosin, Alfuzosin & Silodosin can all be started at therapeutic dose. *Terazosin and Doxazosin must be titrated to therapeutic dose to avoid hypotension (these drugs can also be used to treat hypertension)

____________ calculi is associated with UTI by urease producing bacteria (Klebsiella, proteus), phosphate deficiency and laxative abuse.

Ammonium Acid Urate *Urease hydrolyzes urea into ammonium and bicarb which results in alkaline urine allowing for precipitation of ammonium and carbonate.*

I-PSS (international prostate symptom score) is associated with

BPH

The risk of ______ progression is higher in older men with larger prostate size, higher PSA, lower urine flow rates and more severe LUTS

BPH

What imaging study is used in a renal mass protocol?

CT abd/pelvis without contrast

The most common cause of epididymitis in males <35 is ___________

Chlamydia trachomatis

The most common cause of non-gonococcal urethritis in males is ___________

Chlamydia trachomatis

Spontaneous teste descent after the first year of life is uncommon in patients with ___________. If it in fact does not descend by age 1, then surgery is indicated.

Cryptorchidism

What is the most common genital abnormality in pediatrics?

Cryptorchidism

___________ refers to the absence of the testis from the scrotum

Cryptorchidism Normal descent begins at conception and continues under hormonal control

Testicular cancer treatment

Cure rate is high! •Radical Inguinal Orchiectomy *Further treatment depends on tumor histology and metastatic work-up*

_________ stones is caused by cystinuria. -forms in acidic urine -Radio-opaque -Treatment: Urinary alkalization to dissolve it. *ESWL (shockwave lithotripsy) resistant*

Cystine

Transient incontinence Causes: DIAPERS

Delirium Infection Atrophic vaginitis Pharmaceuticals and psychological Excess urine output (endocrine) Restricted mobility Stool impaction

PDE 5 Inhibitors general MOA

Does not initiate erection, but once erection is induced, it makes the erection stronger

You suspect your patient has testicular torsion based off of his PE. What is the work up?

Doppler scrotal US (no blood flow to the testicle)

What is the most common cause of bacterial prostatitis?

E. coli

What is the most common pathogen that causes pyelonephritis?

E. coli

What is the MC pathogen responsible for cystitis/UTI?

E. coli but also : •Proteus •Klebsiella •S. saprophyticus

Chronic Pelvic Pain Syndrome is a form of non-bacterial prostatitis. What is the treatment?

Empiric course of Bactrim or Cipro If ineffective: -Doxycycline (effective against Ureaplasma and Chlamydia)

On physical exam, the patient has -Normal Cremasteric Reflex -Scrotal swelling with mild erythema -Prehn Sign What is the diagnosis?

Epididymitis

Prostatitis treatment

Extended course of Abx (8-12 weeks) -ciprofloxacin (s/e: tendon rupture) Symptom Control: NSAIDS, alpha blockers and anticholinergics -sitz baths -stress reduction -avoid alcohol, caffeine, spicy, acidic foods -take Saw palmetto Last Resort TURP

What type of testicular torsion? Occurs in neonates as the tunica vaginalis is not adherent to the gubernaculum

Extravaginal

True or False? Gross hematuria is sometimes normal

FALSE Gross hematuria is NEVER normal

True or False? Patient with foley catheter in place will not cause rise in PSA

FALSE it WILL cause a rise in PSA so do not screen

Treatment for Cystitis

First line for UNcomplicated: Nitrofurantoin (Macrobid) *rising resistance to cipro and bactrim* If bacteriuria is asymptomatic, no treatment!

What is the first line treatment for bacterial prostatitis?

Fluoroquinolones

•Unwilling or unable to get to the bathroom secondary to cognitive impairment, physical impairment •No underlying urologic dysfunction •Diagnosis of exclusion •Difficult to treat and frustrating for caretakers

Functional Incontinence

_______ Cell Tumors account for 90-95% of testicular cancers

Germ

Varicocele Grades:

Grade 1 - small, not visible, can only be palpated during valsalva Grade 2 - moderate, not visible, easily palpated with patient standing Grade 3 - large, grossly visible

How can we distinguish between ischemic and non-ischemic priapism?

H&P and cavernosal blood gas

What is the Gleason scale?

How prostate cancer is rated/how aggressive it is

There are 5 categories in the Bosniak Renal Cyst Classification system . Which stages indicate excision?

III and IV

What type of testicular torsion? Torsion of the spermatic cord within the tunica vaginalis

Intravaginal

__________________ priapism is results from decreased venous outflow causing increased intracavernosal pressure leading to erection, decreased arterial inflow, stasis of blood, local hypoxia, and local acidosis. All resulting in a prolonged, painful, fully rigid erection. (medical emergency!!) The longer the episode, the greater that chance of cavernosal fibrosis leading to ED.

Ischemic low-flow

Using Combination Therapy with an alpha blocker + 5 alpha reductase inhibitor can prevent progression of BPH better than monotherapy. What is the name of the medication containing both agents?

Jalyn (tamsulosin + dutasteride)

90% of kidney stones are radio-opaque and thus visible on what gold standard imaging?

KUB

What side of the scrotum are varicoceles most common?

LEFT (due to anatomy of gonadal veins)

BPH symptoms are commonly referred to as ________

LUTS (lower urinary tract symptoms)

_____________ Stones: -aka struvite and triple phosphate -Forms in alkaline urine -Commonly associated with infections -Radio-opaque

Magnesium Ammonium Phosphate *Most staghorn calculi are this type*

Disease states that can cause ED

Medical: ESRD, DM, Liver failure, alcoholism, neurologic disease, thyroid disorders, atherosclerosis Surgical: RRP, radical cystectomy, proctocolectomy, aorto-iliac vascular surgery, AAA repair, penile surgery traumatic: pelvic fracture, penile fracture, priapism, SCI, neuropathy from bicycle riding, pelvic radiation

What technique is used when performing a PE on a patient for Cryptorchidism?

Milk down (iliac crest to scrotum) Pressure over inguinal ring to keep testicle in scrotum

Do ACE-inhibitors cause erectile dysfunction?

NO

On exam, the penis is partially erect, cavernosa are partially rigid and non-tender, but the glans is soft. What type of priapism is this?

Non-ischemic high-flow

___________ priapism results from Increased arterial inflow without decreased venous outflow, leading to a prolonged, non-painful, partially rigid erection without local hypoxia or acidosis. *Not an Emergency* Most resolve without intervention and recover to normal function

Non-ischemic high-flow

Treatment for cryptorchidism

Orchiopexy

What is the first line medication used for erectile dysfunction?

PDE 5 Inhibitors -Viagra -Levitra -Cialis

Prostatitis is inflammation of the prostate. Non-Bacterial Symptoms: -perineal pain -suprapubic pain -back pain -dysuria, frequency, urgency -painful ejaculation It can lead to an increased __________.

PSA *when pt's present with prostatitis, do NOT check a PSA*

Screening for prostate cancer consists of an annual ______ and _____.

PSA and DRE

______________ is a treatment method that removes kidney stones through percutaneous access that traverses through the back and into the kidney.

Percutaneous Nephrolithotomy (PCNL)

Priapism was termed after a fertility god in greek mythology named _________, depicted as having an oversized and permanent erection.

Priapus *you're welcome for the picture*

_________ cancer is the most common internal tumor in U.S. males and the second leading cause of cancer death in U.S. males.

Prostate

Treatment for renal cell carcinoma

Radical Nephrectomy: removal of Gerota's fascia and its contents (kidney, perirenal fat and adrenal Partial Nephrectomy: depends on size and location of the tumor

_________ Prostate Biopsy: •US guidance •Routine Biopsy •12 cores/samples in systematic fashion

Standard

True or False? Most prostate cancers will not cause death

TRUE

_________ Prostate Biopsy: •US guided w/ Artemis device •Fusion of MRI + US •Routine Biopsy of identified targets on MRI

Targeted Fusion

What testicular complaint? MC between the ages of 12 to 16 Sx's = NV due to pain PE= Absent cremasteric reflex and-High-riding testicle

Testicular Torsion

____________ is a urologic emergency that can occur at any age, but is most common between ages 12-18. It presents as acute onset of pain and swelling, often in the middle of the night. Commonly with Nausea and vomiting.

Testicular Torsion

____________ Cell Carcinoma is the most common bladder cancer histology in the U.S.

Transitional

True or False? The severity of BPH symptoms do not always correlate with prostate size or degree of bladder outlet obstruction (BOO).

True

____________ is an endoscopic treatment used for ureteral stones. The stones are fragmented with a holmium laser and can be removed with a stone basket.

Ureteroscopy

Types of incontinence

Urge, stress, overflow, functional, mixed (urge and stress)

____________ Stones: -MCC by dehydration -form in Acidic urine (pH<6.0) -Radiolucent -Dissolves with urinary alkalization -normal serum & uric acid levels

Uric Acid

_________ Erectile Devices are useful in patients that have contraindications to PDE 5 inhibitors (aka. are on nitrates).

Vacuum

____________ is the most common physical finding in subfertile men. Semen shows "strain" pattern -decreased motility -low sperm count -abnormal morphology

Varicocele

*BUZZ WORDS* Child presents with: -hypertension -abdominal mass -hemihypertrophy -aniridia (absent iris) What is the diagnosis?

Wilm's tumor NOTE: May also see GU abnormalities --> Undescended Testicle, hypospadias, ambiguous genitalia

What is the most common primary malignant renal tumor in childhood (3-4 y/o) ?

Wilms Tumor

What is PSA?

a serine protease produced by the prostate -androgen dependent (depends on testosterone) -no fasting required

What is a child's most common presenting symptom/sign of Wilms Tumor?

abdominal mass

What is the most common type of prostate tumor?

adenocarcinoma

Total PSA = %free and complexed PSA % Free PSA is the amount of PSA that remains uncomplexed in the serum. PSA most commonly complexes with __________________

alpha-1 antichymotrypsin

Treatment for gonorrhea and chlamydia is

antibiotics!!! -treat all sex partners within last 60 days or the last known sex partner regardless of last contact

Why are Alpha Blockers first line in BPH treatment?

b/c Alpha 1 receptors are the most prominent adrenergic receptor in the prostate & they act to augment smooth muscle contraction in the prostate stroma and bladder neck

If your patient has incontinence: -Look for reversible causes and treat -Review Medication List -Start with ___________ modifications before medications •Referral if no response to usual measures •Early referral if underlying Urinary tract pathology suspected (elevated PVR)

behavioral

Where is the most common site of cancer in the urinary system and the 4th leading cause of cancer deaths among males?

bladder

Most bladder tumors are found at the T1 stage. If found at T2 or greater, what is the therapy?

bladder removal + new reconstructed bladder

The most common type of kidney stone in the US is ______________.

calcium oxalate (MCC dehydration)

Patients with Chronic Bacterial Prostatitis have an increased incidence of prostatic _____ which could cause recurrent infections

calculi

Neisseria gonorrhea often occurs with _________

chlamydia

Scrotal hydroceles in pediatrics, only containing fluid are called ___________hydroceles.

communicating *hydroceles resolve on own typically*

Erectile dysfunction can be an early sign of ___________

coronary artery disease

____________ refers to infection of the bladder -MC type is UTI -MC from bacterial infection

cystitis

Management of priapism is aimed at ____________, preservation of erectile function and prevention of further episodes.

detumescence (stop swelling/erection)

The exact etiology of acute __________is unclear; however, it is believed to be caused by the abnormal retrograde passage of urine from the prostatic urethra to the epididymis (reflux), induced by Valsalva or strenuous exertion in conjunction with a full bladder

epididymitis

________ is the inability to attain and/or maintain penile erection sufficient for satisfactory sexual performance

erectile dysfunction

Any degree of nephrolithiasis with _____ and ______ must get emergent decompression of the urinary tract and stent placement. (admission/surgery)

fever and leukocytosis

Women are more likely to be affected by UTI's. When do males have a greater incidence?

first year of life

Patient presents with: •+/- Symptoms of acute cystitis •Fevers/Chills •Flank pain •Nausea/Vomiting •Increased WBC count You suspect pyelonephritis. Get Urine culture!!!!!! and Either admit to hospital or treat outpatient with ______________.

fluoroquinolones

What position should the patient be in when evaluating for cryptorchidism?

frog-leg especially useful in obese children & when retractility is a concern *can be in sitting position if needed*

Sedatives cause decreased awareness and detrusor activity leading to which two types of incontinence?

functional and overflow

Prolaris score is a type of _______ testing for prostate cancer.

genomic

If the scrotum has abdominal contents, this is referred to as a __________

hernias *hernias do not resolve on own*

__________ is associated with a patent processus vaginalis in pediatrics. (The processus vaginalis is an extension of the peritoneum that accompanies the testicle on its descent into the scrotum from the abdomen)

hydrocele

If an adult patient has a hydrocele but you are unable to palpate the testicle, you must do an US because:

hydrocele formation can accompany testicular cancer

Treatment for bothersome hydroceles

hydrocelectomy

The most common metabolic cause of kidney stones is ___________

hypercalciuria

What is the classic finding on scrotal US of a patient with epididymitis?

hyperemia (increased blood flow) of the epididymis **over 90% sensitive**

If Pyelonephritis goes untreated, it can lead to renal scarring, which can lead to _____________

hypertension

What occurs in about 65% of all children with Wilm's tumor?

hypertension

Myrbetriq is a beta-3 adrenergic agonist. These receptors are located on the bladder wall promoting urine storage through bladder relaxation. What is a possible side effect of Myrbetriq?

hypertension (NO cognitive s/e which is great :) )

MUSE Intraurethral alprostadil produces an erection within 5-20 minutes after dosing. What is the most common adverse effect after the first dose?

hypotension

___________ is the inability to store urine in the bladder without leakage / involuntary loss of urine that is objectively demonstrable and is a social or hygienic problem

incontinence (more common in females)

Presence of penile abnormality + cryptorchidism could indicate _________ which is a potential emergency in the neonate

intersex

In a patient with Cryptorchidism, the testes are usually palpable and are either truly undescended, ectopic, or retractile. Non-palpable testis are either ____________ or absent

intraabdominal

Chlamydia is an _________ organism

intracellular

When are PDE 5 inhibitors contraindicated?

is patient is on nitrates!

On exam, the penis is fully erect, the cavernosa are rigid and tender, but the glans is soft. What type of priapism is this?

ischemic low-flow

Phimosis is a normal condition in children, usually resolving by age 5-7. What do you advise the patient if they ask about pulling the foreskin back?

it should never be forcibly retracted as this can cause scarring of the foreskin

%Free PSA greater than 25% means that the patient is (less/more) likely to have prostate cancer.

less the higher the free PSA %, the better the chances of NOT getting prostate cancer the higher the total PSA, the MORE chance of prostate cancer

What is the most common cause of stress incontinence?

loss of pelvic support from child birth

A unilateral right sided varicocele or a varicocele that is rapid in onset could indicate compression of the veins within the abdomen. This should spark concern for possible ____________.

malignancy (order CT of the abdomen/pelvis)

Paraphimosis is a medical emergency as it can cause swelling of the glans and loss of blood flow. What is the treatment?

manual decompression + reduction of foreskin. If that does not work: -dorsal slit -circumcision

Paraneoplastic Syndromes occur in 30% of patients w/ Renal Cell Carcinoma. If the symptoms persist after tumor resection, there is __________ disease.

metastatic

Positive RBCs on a dipstick should always be confirmed with __________.

microscopic analysis

How are the grade groups in the Gleason scale calculated? Group 1 = Gleason score ≤ 6 Group 2 = Gleason score 3 + 4 = 7 Group 3 = Gleason score 4 + 3 = 7 Group 4 = Gleason score 8 Group 5 = Gleason scores 9 & 10

most prevalent pattern + the second most prevalent pattern The higher the sum, the worse the prognosis.

Orchitis is an acute inflammatory reaction of the testis to infection. Most cases are due to _________ in prepubertal boys. Unilateral testicular atrophy Infertility is rare

mumps

Neisseria gonorrhea is a gram __________ diplococci.

negative

As men age, there is an increase in the amount of prostate stroma and increase in the number of alpha 1 receptors which can lead to __________ of urinary flow. Alpha 1 blockers treat BPH by blocking these receptors and relaxing the smooth muscle

obstruction

When prostates are severely enlarged, endoscopic treatment is not recommended, instead the prostate is removed via ___________

open prostatectomy (Rare)

Diuretics overwhelms bladder capacity leading to which two types of incontinence?

overflow and urge

What type of incontinence is "dangerous" as it can cause renal failure if left untreated?

overflow incontinence

•Continuous small volume leakage •Abdominal distention, pain •Hesitancy, Nocturia •Urinary retention (acute or chronic)

overflow incontinence

Hydroceles in adults are non-communicating and painless. Surgery is only indicated if __________ is present.

pain (from amount of fluid)

What is it called when the foreskin is trapped behind the glans and cannot be reduced?

paraphimosis

Symptoms of mumps orchitis typically follow __________ by 5-7 days Symptoms include: testicular pain and swelling

parotitis

Diagnostic testing to evaluate for stress incontinence:

pelvic exam with valsalva *Urodynamic Testing in complex cases*

What is the last resort when all other erectile dysfunction treatments fail?

penile prosthesis

What is the common cause of Non-ischemic high-flow priapism?

perineal or penile trauma (fistula between the corpora and cavernosal artery)

Most prostate cancers arise on the ___________ zone

peripheral

_________ is when the foreskin cannot be fully retracted over the glans

phimosis

Why is DRE important in the absence of an elevated PSA?

possible non-PSA secreting tumors

Intracavernosal Injections are associated with an increased risk of __________

priapsim

What is the most important thing to do after placing a foley catheter in a patient with paraphimosis?

replace the foreskin

Hydroceles are most common on the _________ side and more common in premature infants.

right

Which testicle is the most commonly associated with undescended testicle and thus testicular cancer?

right

Patient presents with testicular pain. What imaging study is always indicated in this case?

scrotal ultrasound ALWAYS

Dipstick for RBCs is highly _________, but less _________.

sensitive specific

Acute epididymitis is characterized by the onset of epididymal pain and swelling over what time period?

several days

Bladder cancer is most commonly caused by __________*****

smoking Other risk factors: -Chronic cystitis -Chronic UTI -Chronic catheterization -bladder stones -schistosomiasis -Chemical Exposures -Radiation Exposure -Cyclophosphamide

__________ is the involuntary loss of urine secondary to increase in abdominal pressure with inability to keep the urinary sphincter closed. *2nd MC type of incontinence in females*

stress incontinence

14 year old male wakes up in excrutiating testicular pain. He played soccer last night with his friends and denies any known injury. On exam, you see a high-riding testicle. What is the patients diagnosis?

testicular torsion *must try to correct within 4 hours due to lack of blood flow!*

Where does BPH occur?

transition zone

True or False? Non-obstructing stones do not cause pain.

true

True or False? A unilateral varicocele can affect both testicles causing bilateral atrophy and damage

true

Caffeine causes polyuria and increased detrusor activity leading to what type of incontinence?

urge

Cholinergics cause increased detrusor activity leading to what type of incontinence?

urge

What is the most common type of incontinence?

urge

Alcohol causes polyuria with decreased awareness leading to which two types of incontinence?

urge and functional

Involuntary urine loss secondary to uninhibited bladder contractions -unpredictable/sudden -PVR normal "Key in the Door" Syndrome "Foot on the Floor" Syndrome Bathroom Mapping

urge incontinence

All Anticholinergics and beta agonists work by depressing detrusor activity and can lead to ______ ______. Check post-void residual urine prior to prescribing

urinary retention.

____________ is the branch of medicine that focuses on the surgical and medical diseases of the male and female urinary tract system and the male reproductive organs. includes: kidneys, adrenal glands, ureters, urinary bladder, urethra, and the male reproductive organs (testes, epididymis, vas deferens, seminal vesicles, prostate and penis).

urology

___________ is a group of dilated veins in the pampiniform plexus (network of many small veins found in the spermatic cord)

varicocele

Decreases in PSA can be caused by:

•5 alpha reductase inhibitors (Finasteride, Dutasteride) •androgen deprivation/castration •Prostate surgery •Radiation Therapy

What PE findings would you expect to see in a patient with testicular torsion?

•Absent Cremasteric Reflex •Tender, firm testicle •High riding testicle •Horizontal testicle •No pain relief with elevation of testicle

What are the risk factors for kidney stones (nephrolithiasis)? *ALOT*

•Anatomic (urinary obstruction or stasis) •Urine composition (pH, stone forming substances) •DEHYDRATION Urine volume/hydration status (leads to crystal formation) •DIET •Urinary Tract Infection •Sedentary Lifestyle •Hypercalciuria (Hyperparathyroidism) •Hypocitraturia •Hyperoxaluria (excess tea, chocolate, peanuts, spinach) - Bowel disease •Hyperuricosuria •Hypomagnesuria •Chronic diarrhea •Type I RTA •Sarcoidosis (hypercalciuria) •Cystinuria (genetic, starts at an early age) •Medullary Sponge Kidney •Adult Polycystic Kidney Disease •Vitamin C (metabolized to oxalate) •Vitamin D (Increases Calcium absorption) •Triamterene •Indinavir (stones are formed of drug precipitants) •Furosemide (increases calcium excretion) •Acetazolamide and Uricosuric agents

What medications are known to cause Erectile Dysfunction?

•Anti-hypertensives (B blockers, thiazides, clonidine and methyldopa) •Anti-depressants (delayed) •anti-psychotics, (TCA, MAOi, lithium and phenothiazines) •Cimetidine and Spironolactone both block/reduce testosterone •Sedatives, alcohol, phenytoin, smoking, anticholinergics

Treatment for epididymitis

•Antibiotics •Scrotal elevation/tight fitting underwear •Anti-inflammatories •Warm Sitz Baths •Reduce exertion/exercise

You suspect that your patient has a kidney stone. What is the work up?

•CBC, CMP, UA, Urine culture •KUB, CT stone protocol (NO CONTRAST)

Work up for Renal Tumor

•CT and CXR •Neuro Exam •CBC, BUN/Cr, LFTs, Alk Phos, Calcium *Alk Phos is to look for bony metastases!!*

Erectile Function depends on 2 main events:

•Cavernosal artery smooth muscle relaxation-active •Increased venous outflow resistance-passive (High inflow with low outflow)

What are the consequences of incontinence? *primarily urge*

•Cellulitis, Pressure Ulcers •Falls/fractures •sleep deprivation •social withdrawal, depression •Embarrassment/isolation •Increased caregiver burden

You suspect Wilm's tumor in your 4 year old patient. What is the workup?

•Check BP! •CBC, BUN/Cr, LFTs, Calcium, UA (Alk phos will be abnormal) •US first!! •CT, CXR •Bone scan

What are the Indications for Admission and Surgical Intervention for nephrolithiasis?

•Complete or high grade unilateral obstruction •Any degree of bilateral obstruction •Any degree of obstruction with fever and leukocytosis (FEAR SEPSIS) •Any degree of obstruction with azotemia •Obstruction in patients with DM or immunocompromised •Intractable nausea and vomiting •Uncontrolled pain

Age Related Changes in the Urinary Tract leading to incontinence include:

•Detrusor Overactivity •BPH •Atrophic Vaginitis •Decreased ability to postpone urination, decreased total bladder capacity, decreased detrusor contractility •Increased PVR, nocturia, Increased urine output later in the day •Decreased urine concentrating ability, decreased flow

What is Phren Sign?

•Elevation of the testicle relieves pain because the weight is taken off of the epididymal suspension

What is the diagnostic workup of a patient you suspect has varicoceles?

•Examine in supine and upright position •Valsalva Maneuver • "Bag of Worms"

Prostate Cancer risk factors

•FHx (first degree relative) •African American Race •Higher Age (>65)

Symptoms of acute bacterial prostatitis

•Fever •Irritative and/or obstructive voiding •Tender, warm, boggy prostate

What are the symptoms of Epididymitis?

•Gradual onset of pain/swelling of the testicle •unilateral •Fevers/chills maybe •+/- dysuria, urgency and frequency

If patient presents with symptoms of Acute Bacterial Prostatitis, Avoid prostate massage and urethral instrumentation secondary to risk of sepsis! What is the plan?

•Hospital admission with IV antibiotics •If symptoms persist despite treatment, pelvic CT should be done to look for a prostate abscess

When is repair of varicoceles indicated?

•If Symptomatic •Palpable varicocele and abnormal semen analysis •Adolescent with varicocele and ipsilateral testicular atrophy (repair may reverse atrophy, but has not been proven to prevent infertility)

Risk factors for incontinence

•Impaired Mobility •Depression •Stroke •Diabetes •Parkinson's Disease •Dementia •Obesity •Chronic cough/COPD •Constipation •Medications •alcohol •sedatives

General Dietary Guidelines for Stone Formers:

•Increase fluid intake (Urine volume should be 2-3 L/day) Rule of 8's •Low Sodium (salt is excreted with calcium) •Low Oxalate •Recommended daily allowance of Calcium •Avoid high doses of Vitamins C & D •Low animal protein diet

DDx testicular cancer before US

•Infection •Hydrocele •Torsion •Hematoma •Spermatocele (epidydimal cyst)

DDx for hematuria include

•Menses •Prostate •Obstructive Uropathy •Trauma •Tumor (Bladder, Kidney, Ureteral, Urethral) •Kidney Stones •Thrombosis •Hematologic (anticoagulation, Sickle Cell, bleeding disorders) •Infection/Inflammation •H/o Radiation

Males with gonorrhea

•Most are symptomatic •Urethritis- purulent urethral discharge •Epididymitis •Prostatitis •Can lead to urethral stricture

Females with gonorrhea

•Most females are not symptomatic •Urethritis •Cervicitis •PID •Fitz-Hugh-Curtis syndrome (peri-hepatitis)

What drugs can cause incontinence by depressing detrusor activity?

•Opioids •CCB's •Anticholinergics •Anti-Parkinson's Drugs •Prostaglandin Inhibitors (NSAIDS)

Gonorrhea in Males and Females can cause

•Pharyngitis •Proctitis •arthralgia, rash, fever, tenosynovitis •endocardititis, meningitis, hepatitis, conjunctivitis

What constitutes as a complicated UTI?

•Pregnancy •Structural or Functional abnormality of the urinary tract •Unusual pathogen •Recent instrumentation •Recent antibiotic use

Risk factors of Cryptorchidism:

•Prematurity •Low birth weight/small size for gestational age •Twin gestation •Maternal exposure to estrogen in the first trimester

When should surgery be considered in a BPH patient?

•Recurrent/Persistent urinary retention •Recurrent UTI •Recurrent/Persistent Gross Hematuria •Bladder Stones •Renal Insufficiency Surgery types: -TURP (picture) -TUNA -TUMT -laser evap. -plasma vaporization -UROLIFT

Treating Erectile Dysfunction

•STOP Smoking •Lose Weight •Stop Alcohol •Evaluate meds •Optimize HTN and DM management

You suspect testicular cancer. What is the work-up?

•Scrotal Ultrasound •Tumor Markers: AFP, B HCG, LDH •BUN, Cr, LFTs •Chest imaging •Abdominal CT scan •Neuro Exam, if abnormal, get Head CT *Consider Sperm Banking*

Pyelonephritis occurs from one of two pathways:

•Seeding of the kidneys from bacteremia (IV drug abuse, obstruction of the urinary tract) •Ascension of bacteria from the lower urinary tract

Treatment for testicular torsion

•Surgery •Once the patient begins to have pain, the testicle must be detorsed within 6 hours •If non-viable, perform orchiectomy •If viable, perform orchiopexy Contralateral orchiopexy is performed in either case

Treatments for Prostate Cancer

•Surgery •Radiation/Chemo •Hormonal, surgical or chemical castration •Cryotherapy •HIFU •Active Surveillance

Treatment for Wilms Tumor

•Surgical exploration & removal •Chemotherapy if: 1. tumor is unresectable at presentation 2. bilateral involvement 3. extensive intracaval involvement **Survival is very good**

What is the management of urge incontinence?

•Timed Voiding •Avoid Caffeine •Anticholinergics •Beta agonist Other: -botox (chemodenervation) -interstim therapy (sacral nerve neuromodulation) -PTNS (percutaneous tibial nerve stimulation)

Bladder cancer treatment

•Transurethral Resection of Bladder Tumor •Intravesical Chemotherapy •Intravesical Immunotherapy •Radical Cystectomy

You suspect your patient has Epididymitis. What is the workup?

•UA +/- Urine culture •Urethral Swab •Scrotal doppler US

Chlamydia in females can cause

•Urethritis •Cervicitis •PID •Proctitis •Conjunctivitis •Endocarditis

Chlamydia in males can cause

•Urethritis- clear urethral discharge •Epididymitis •Prostatitis-rare •Proctitis •Conjuctivitis •Endocarditis

Symptoms of Cystitis include

•Urgency •Frequency •Dysuria •Suprapubic pain •Gross Hematuria •AMS in elderly

What is the workup of a patient who comes in complaining of blood in their urine?

•Urinalysis/Urine Culture •Urine Cytology •Cystoscopy •Upper Tract Imaging (3 phase CT scan) - CT Abd/Pelvis with and without contrast NOTE: *stones show up without contrast and masses show up with contrast*

Risk Factors for Cystitis/UTI

•Urinary Retention •Catheterization •Atrophic Vaginitis •Immunosuppression •Diabetes •Pregancy

What are some causes of erectile dysfunction?

•Vasculogenic (arterial or venous) •Neurogenic •Psychogenic •Endocrinologic •Medication Induced

What are the paraneoplastic syndromes associated with renal cell carcinoma?

•fever, weight loss, cachexia, elevated ESR •anemia, hypercalcemia, polycythemia •hypertension (elevated renin) •hypercalcemia •Stauffer's syndrome (hepatitis not associated with liver mets)

Increases in PSA can be caused by:

•prostate cancer •BPH, prostatitis •Age (naturally elevates with age) •manipulation or trauma (DRE for example) •Ejaculation (refrain for 1-2 weeks before checking PSA