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58 Cards in this Set
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- Back
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A 14-year old boy presents in the ER with very severe pain of sudden onset in his right testicle. There is NO fever, pyuria, or history of recent mumps. The testis is swollen, exquisitely painful, "high riding," and with a "horizontal lie." The cord is not tender.
What is this? |
Testicular torsion, a urologic emergency |
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A 14-year old boy presents in the ER with very severe pain of sudden onset in his right testicle. There is NO fever, pyuria, or history of recent mumps. The testis is swollen, exquisitely painful, "high riding," and with a "horizontal lie." The cord is not tender.
How should this patient be managed? |
Emergency surgery to save testicle. Do not waste time doing diagnostic studies. |
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A 24-year old man presents in the ER with very severe pain of recent onset in his right scrotal contents. There is a fever of 103 degrees F and pyuria. The testis is in the normal position, and it appears to be swollen and exquisitely painful. The cord is also very tender.
What is this? |
Acute epididymitis |
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A 24-year old man presents in the ER with very severe pain of recent onset in his right scrotal contents. There is a fever of 103 degrees F and pyuria. The testis is in the normal position, and it appears to be swollen and exquisitely painful. The cord is also very tender.
How should this patient be managed? |
This is the condition that presents the differential diagnosis with testicular torsion. Torsion is a surgical emergency. Epididymitis is not an emergency. Don't rush this guy to the OR, all he needs are ANTIBIOTICS.
If by chance the diagnosis of testicular torsion is missed, the medicolegal implications are so bad that urologists routinely do a SONOGRAM to rule out torsion.
tl;dr: ANTIBIOTICS and SONOGRAM (r/o torsion) |
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A 72-year old man is being observed with a ureteral stone that is expected to pass spontaneously. He develops chills, a temperature spike to 104 degrees F, and flank pain.
What is this? |
Obstruction of the urinary tract alone is bad. Infection of the urinary tract alone is bad.
The combination of the OBSTRUCTION and INFECTION is a true urologic emergency. |
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A 72-year old man is being observed with a ureteral stone that is expected to pass spontaneously. He develops chills, a temperature spike to 104 degrees F, and flank pain.
How should this patient be managed? |
Massive IV ANTIBIOTIC therapy, but the obstruction must be relieved right now.
In a septic patient stone extraction would be hazardous, thus the option in addition to antibiotics would be decompression by URETERAL STENT or PERCUTANEOUS NEPHROSTOMY
tl;dr: IV antibiotics + decompression (urethral stent or percutaneous nephrostomy) |
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An adult woman relates that 5 days ago she began to notice frequent, painful urination with small volumes of cloudy and malodorous urine. For the first 3 days she had no fever, but the past 2 days she has been having chills, high fever, nausea, and vomiting. Also in the past 2 days she has had pain in the right flank. She has had no treatment whatsoever up to this time.
What is this? |
Pyelonephritis |
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An adult woman relates that 5 days ago she began to notice frequent, painful urination with small volumes of cloudy and malodorous urine. For the first 3 days she had no fever, but the past 2 days she has been having chills, high fever, nausea, and vomiting. Also in the past 2 days she has had pain in the right flank. She has had no treatment whatsoever up to this time.
How should this patient be managed? |
UTI should not happen in men or in children, and thus they should trigger a workup looking for a cause.
Women of reproductive age, on the other hand, get cystitis all the time, and are treated with appropriate ANTIBIOTICS without great fuss.
However, when they get flank pain and septic signs it is a different story. This woman needs hospitalization, IV ANTIBIOTICS, and at least a SONOGRAM to make sure there is no concomitant obstruction. |
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A 62-year old man presents with chills, fever, dysuria, urinary frequency, diffuse low back pain, and an exquisitely tender prostate on rectal exam.
What is this? |
Acute bacterial prostatitis |
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A 62-year old man presents with chills, fever, dysuria, urinary frequency, diffuse low back pain, and an exquisitely tender prostate on rectal exam.
How should this patient be managed? |
He should receive IV ANTIBIOTICS
He should not have any more rectal exams or any vigorous prostatic massage. Doing so could lead to septic shock. |
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A 33-year old man has urgency, frequency, and burning pain with urination. The urine is cloudy and malodorous. He has mild fever. On physical exam the prostate is NOT warm, boggy, or tender.
What is this? |
The first part of the vignette sounds like prostatitis, which would be common and not particularly challenging
BUT, if the prostate is normal on exam the ante is raised: this is a UTI, but men (particularly young ones) are not supposed to get UTIs |
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A 62-year old man presents with chills, fever, dysuria, urinary frequency, diffuse low back pain, and an exquisitely tender prostate on rectal exam.
How should this patient be managed? |
This infection (UTI) needs to be treated, so ask for urinary CULTURES and start ANTIBIOTICS - but also start a urologic workup.
Urologic workup: do not start with cystoscopy (do not instrument an infected bladder, you could trigger septic shock). Start first with a SONOGRAM.
tl;dr: antibiotics, urine culture, sonogram |
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You are called to the nursery to see an otherwise healthy-looking newborn boy because he has not urinated in the first 24 hours of life. Physical exam shows a big distended urinary bladder.
What is this? |
Kids are not born alive if they have no kidneys (without kidneys, lungs do not develop). This represents some kind of obstruction.
First look at the meatus: it could be simple MEATAL STENOSIS. If it is not, POSTERIOR URETHRAL VALVES is the most likely reason. |
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You are called to the nursery to see an otherwise healthy-looking newborn boy because he has not urinated in the first 24 hours of life. Physical exam shows a big distended urinary bladder.
How should this patient be managed? |
Drain the bladder with a catheter (it will pass through the valves).
Voiding cystourethrogram for diagnosis, endoscopic fulguration or resection for treatment. |
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A bunch of newborn boys are lined up in the nursery for you to do circumcisions. You notice that one of them has the urethral opening in the ventral side of the penis, about midway down the shaft.
What is this? |
Hypospadias |
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A bunch of newborn boys are lined up in the nursery for you to do circumcisions. You notice that one of them has the urethral opening in the ventral side of the penis, about midway down the shaft.
How should this patient be managed? |
This patient should not have a circumcision. The foreskin may be needed later for reconstruction when the hypospadias is surgically corrected |
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A 7-year old child falls off a jungle gym and has minor abrasions and contusions. When checked by his pediatrician, a urinalysis shows microhematuria.
What is this? |
Hematuria from trivial trauma - could mean a congenital anomaly in a child! |
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A 7-year old child falls off a jungle gym and has minor abrasions and contusions. When checked by his pediatrician, a urinalysis shows microhematuria.
How should this patient be managed? |
Start with SONOGRAM to evaluate for congenital anomaly |
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A 9-year old boy gives a history of 3 days of burning on urination, with frequency, low abdominal and perineal pain, left flank pain, and fever and chills.
What is this? |
Little boys are not supposed to get UTIs. There is more than meets the eye here. A congenital anomaly has to be ruled out. |
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A 9-year old boy gives a history of 3 days of burning on urination, with frequency, low abdominal and perineal pain, left flank pain, and fever and chills.
How should this patient be managed? |
Treat the infection of course, but do IVP and voiding cystogram to look for reflux. If reflux is found, long-term antibiotics while the child "grows out of the problem". |
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A mother brings her 6-year old girl to you because she has "failed miserably to get proper toilet training". On questioning you find out that the little girl perceives normally the sensation of having to void and voids normally and at appropriate intervals, but also happens to be wet with urine all of the time.
What is this? |
Low implantation of one ureter: - In little boys, there would be no symptoms because low implantation in boys is still above the sphincter. - In little girls, the low ureter enters into the vagina and has no sphincter. The other ureter is normally implanted and accounts for the normal voiding pattern |
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A mother brings her 6-year old girl to you because she has "failed miserably to get proper toilet training". On questioning you find out that the little girl perceives normally the sensation of having to void and voids normally and at appropriate intervals, but also happens to be wet with urine all of the time.
How should this patient be managed? |
- Physical exam: look for abnormal ureteral opening - If no abnormality observed on exam, imaging studies would be required (start with IVP) - Surgery will follow |
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A 16-year old boy goes on a beer-drinking binge for the first time in his life. Shortly thereafter he develops colicky flank pain.
What is this? |
Ureteropelvic junction obstruction |
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A 16-year old boy goes on a beer-drinking binge for the first time in his life. Shortly thereafter he develops colicky flank pain.
How should this patient be managed? |
Start with ultarsound (sonogram) to confirm ureteropelvic junction obstruction. Repair will follow. |
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A 62-year old man reports an episode of gross, painless hematuria. Further questioning determines that the patient has total hematuria rather than initial or terminal hematuria.
What is this? |
Blood is coming from anywhere from the kidneys to the bladder, rather than the prostate or the urethra. Either infection or tumor can produce hematuria.
In older patients without signs of infection, cancer is the main concern, and it could be either RENAL CELL CARCINOMA or TRANSITIONAL CELL CARCINOMA of the bladder or ureter |
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A 62-year old man reports an episode of gross, painless hematuria. Further questioning determines that the patient has total hematuria rather than initial or terminal hematuria.
How should this patient be managed? |
CT scan and cystoscopy to workup for renal cell carcinoma or transitional cell cancer of bladder or ureter |
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A 70-year old man is referred for evaluation because of a triad of hematuria, flank pain, and a flank mass. He also has hypercalcemia, erythrocytosis, and elevated liver enzymes.
What is this? |
Full-blown picture of renal cell carcinoma (very rarely seen nowadays) |
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A 70-year old man is referred for evaluation because of a triad of hematuria, flank pain, and a flank mass. He also has hypercalcemia, erythrocytosis, and elevated liver enzymes.
How should this patient be managed? |
Do a CT scan to look for renal cell carcinoma |
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A 55-year old chronic smoker reports three instances in the past 2 weeks when he has had painless, gross, total hematuria. In the past 2 months he has been treated twice for irritative voiding symptoms, but has not been febrile, and urinary cultures have been negative.
What is this? |
Most likely bladder cancer |
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A 55-year old chronic smoker reports three instances in the past 2 weeks when he has had painless, gross, total hematuria. In the past 2 months he has been treated twice for irritative voiding symptoms, but has not been febrile, and urinary cultures have been negative.
How should this patient be managed? |
Do a CT scan and cystoscopy to check for bladder cancer |
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A 59-year old black man has a rock-hard discrete 1.5 cm nodule felt in his prostate during a routine physical exam?
What is this? |
Early cancer of the prostate |
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A 59-year old black man has a rock-hard discrete 1.5 cm nodule felt in his prostate during a routine physical exam?
How should this patient be managed? |
Transrectal needle biopsy, guided by the examining finger. Eventually surgical resection or radiotherapy after the extent of the disease has been established. |
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A 59-year old black man is told by his PCP that his prostatic specific antigen (PSA) has gone up significantly since his last visit. He has no palpable abnormalities in his prostate by rectal exam.
What is this? |
Early cancer of the prostate |
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A 59-year old black man is told by his PCP that his prostatic specific antigen (PSA) has gone up significantly since his last visit. He has no palpable abnormalities in his prostate by rectal exam.
How should this patient be managed? |
Transrectal needle biopsy, guided by sonogram. Eventual surgical resection or radiotherapy after the extent of the disease has been established. |
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A 62-year old man had a radical prostatectomy for cancer of the prostate 3 years ago. He now presents with widespread bony pain. Bone scans show metastases throughout the entire skeleton, including several that are very large and very impressive.
How should this patient be managed? |
Significant, often dramatic palliation can be obtained with ORCHIECTOMY, although it will not be long-lasting (1-2 years only).
An expensive alternative is leutinizing hormone-releasing hormone agonist, and another option is anti-androgens (flutamide). |
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A 78-year old man comes in for a routine medical checkup. He is asymptomatic. When a physician had seen him 5 years earlier, a PSA had been ordered, but he notices as he eaves the office this time that the study has not been requested. He asks if he should get it.
How should this patient be managed? |
For many years PSAs were not done after age 75. Improved longevity and better treatments for early prostatic cancer have led to a more flexible approach. If this man is in good general health, he should get the test. |
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A 25-year old man presents with a painless, hard testicular mass. It is clear in the physical exam that the mass arises from the testicle rather than the epididymus. To be sure, a sonogram was done. The mass was indeed testicular.
What is this? |
Testicular cancer |
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A 25-year old man presents with a painless, hard testicular mass. It is clear in the physical exam that the mass arises from the testicle rather than the epididymus. To be sure, a sonogram was done. The mass was indeed testicular.
How should this patient be managed? |
Diagnosis is made by performing a RADICAL ORCHIECTOMY by the inguinal route. This is an irreversible, drastic step performed because testicular tumors are almost never benign.
Beware of the option to do a trans-scrotal biopsy; that is a definite no-no.
Further treatment will include LN dissection in some cases and platinum-based chemotherapy.
Serum markers are useful for follow up: alpha-fetoprotein and beta-human chorionic gonadotropin, and they have to be drawn BEFORE the orchiectomy (but they do not determine the need for diagnostic orchiectomy - that still needs to be done) |
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A 25-year old man is found on pre-employment chest x-ray to have what appears to be a pulmonary metastasis from an unknown primary tumor. Subsequent physical exam discloses a hard testicular mass, and the patient indicates that for the past 6 months he has been losing weight for no obvious reason.
What is this? |
Testicular cancer - but with metastasis. The point of this vignette is that testicular cancer responds so well to chemotherapy that treatment is undertaken regardless of the extent of the disease when first diagnosed. |
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A 25-year old man is found on pre-employment chest x-ray to have what appears to be a pulmonary metastasis from an unknown primary tumor. Subsequent physical exam discloses a hard testicular mass, and the patient indicates that for the past 6 months he has been losing weight for no obvious reason.
How should this patient be managed? |
Diagnosis is made by performing a RADICAL ORCHIECTOMY by the inguinal route. This is an irreversible, drastic step performed because testicular tumors are almost never benign.
Beware of the option to do a trans-scrotal biopsy; that is a definite no-no.
Further treatment will include LN dissection in some cases and platinum-based chemotherapy.
Serum markers are useful for follow up: alpha-fetoprotein and beta-human chorionic gonadotropin, and they have to be drawn BEFORE the orchiectomy (but they do not determine the need for diagnostic orchiectomy - that still needs to be done) |
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A 60-year old man shows up in the ER because he has not been able to void for the past 12 hours. He wants to but cannot. On physical exam his bladder is palpable halfway up between the pubis and the umbilicus, and he has a big, boggy prostate gland without nodules. He gives a history that for several years now he has been getting up 4-5 times a night to urinate. Because of a cold, 2 days ago he has been taking anti-histamines, using "nasal drops", and drinking plenty of fluids.
What is this? |
Acute urinary retention, with underlying benign prostatic hypertrophy |
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A 60-year old man shows up in the ER because he has not been able to void for the past 12 hours. He wants to but cannot. On physical exam his bladder is palpable halfway up between the pubis and the umbilicus, and he has a big, boggy prostate gland without nodules. He gives a history that for several years now he has been getting up 4-5 times a night to urinate. Because of a cold, 2 days ago he has been taking anti-histamines, using "nasal drops", and drinking plenty of fluids.
How should this patient be managed? |
Indwelling bladder catheter, to be left in for at least 3 days.
Further management will be based on the use of alpha-blockers. Other options include 5-alpha-reductase inhibitors for large glands, or newly developed non-invasive interventions.
The traditional TURP is rarely done now. |
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On the second post-op day after surgery for repair of bilateral inguinal hernias, the patient reports that he "cannot hold his urine". Further questioning reveals that every few minutes he urinates a few mL of urine. On physical exam there is a large palpable mass arising from the pelvis and reaching almost to the umbilicus?
What is this? |
Acute urinary retention with overflow incontinence |
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On the second post-op day after surgery for repair of bilateral inguinal hernias, the patient reports that he "cannot hold his urine". Further questioning reveals that every few minutes he urinates a few mL of urine. On physical exam there is a large palpable mass arising from the pelvis and reaching almost to the umbilicus?
How should this patient be managed? |
Indwelling bladder catheter |
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A 42-year old woman consults you for urinary incontinence. She is the mother of five children and ever since the birth of the last one, 7 years ago, she leaks a small amount of urine whenever she sneezes, laughs, gets out of a chair, or lifts any heavy objects. She relates that she can hold her urine all through the night without any leaking whatsoever.
What is this? |
Stress incontinence |
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A 42-year old woman consults you for urinary incontinence. She is the mother of five children and ever since the birth of the last one, 7 years ago, she leaks a small amount of urine whenever she sneezes, laughs, gets out of a chair, or lifts any heavy objects. She relates that she can hold her urine all through the night without any leaking whatsoever.
How should this patient be managed? |
If she has no physical findings, she can be taught exercises to strengthen the pelvic floor. If she has a large cystocele, she will need surgical reconstruction. |
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A 72-year old man who in previous years has passed a total of three urinary stones is having symptoms of ureteral colic. He has relatively mild pain that began 6 hours ago and does not have much in the way of nausea and vomiting. CT scan shows a 3-mm ureteral stone just proximal to the ureterovesical junction.
How should this patient be managed? |
There are many options for treating stones, including laser beams, shock waves, ultrasonic probes, baskets for extraction, etc.
There is still a role for watching and waiting. This man is a good example - he has a small stone, almost at the bladder. Give him TIME, PAIN MEDS, and plenty of FLUIDS, and he will probably pass it. |
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A 54-year old woman has severe ureteral colic. CT scan shows a 7-mm ureteral stone at the ureteropelvic junction.
How should this patient be managed? |
Whereas a 3mm stone has a 70% chance of passing, a 7mm stone has only a 5% probability of doing so.
This one will have to be smashed and retrieved. Best option is SHOCK WAVE LITHOTRIPSY (SWL).
Contraindications to SWL include pregnancy, bleeding diathesis, and stones that are several cm big. |
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A 72 year old man consults you with a history that for the past several days he has noticed that bubbles of air come out along with the urine when he urinates. He also gives symptoms suggestive of mild cystitis.
What is this? |
Pneumaturia caused by a fistula between the bowel and bladder. Most commonly from sigmoid colon to dome of bladder, caused by diverticulitis. Cancer (also originating in sigmoid) is the second possibility. |
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A 72 year old man consults you with a history that for the past several days he has noticed that bubbles of air come out along with the urine when he urinates. He also gives symptoms suggestive of mild cystitis.
How should this patient be managed? |
Cystoscopy or sigmoidoscopy rarely shows anything. Contrast studies (cystogram or barium enema) are also typically unrewarding.
*CT scan will rule out cancer of sigmoid - Sigmoidoscopic exam would also be done at some point but not the first test - Eventually surgery will be needed |
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A 32-year old man has sudden onset of impotence. One month ago he was unexpectedly unable to perform with his wife after an evening of heavy eating and heavier drinking. Ever since then he has not been able to achieve an erection when attempting to have intercourse with his wife, but he still gets nocturnal erections and can masturbate normally.
What is this? |
Classic psychogenic impotence - young man, sudden onset, partner-specific |
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A 32-year old man has sudden onset of impotence. One month ago he was unexpectedly unable to perform with his wife after an evening of heavy eating and heavier drinking. Ever since then he has not been able to achieve an erection when attempting to have intercourse with his wife, but he still gets nocturnal erections and can masturbate normally.
How should this patient be managed? |
Curable with psychotherapy if PROMPTLY done |
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Ever since he had a motorcycle accident where he crushed his peritoneum, a young man has been impotent.
What is this? |
Organic impotence - has sudden onset and related to trauma. Vascular injury is the likely cause. |
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Ever since he had a motorcycle accident where he crushed his peritoneum, a young man has been impotent.
How should this patient be managed? |
Vascular reconstruction may help |
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Ever since he had abdominoperineal resection for cancer of the rectum, a 52-year old man has been impotent.
What is this? |
Organic impotence - likely secondary to nerve injury |
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Ever since he had abdominoperineal resection for cancer of the rectum, a 52-year old man has been impotent.
How should this patient be managed? |
Only prosthetic devices can help |
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A 66-year old diabetic man with generalized arteriosclerotic occlusive disease notices gradual loss of erectile function. At first he could get erections, but they did not last long; later the quality of the erection was poor; and eventually he developed complete impotence. He does not get nocturnal erections.
What is this? |
Organic impotence (not related to trauma) |
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A 66-year old diabetic man with generalized arteriosclerotic occlusive disease notices gradual loss of erectile function. At first he could get erections, but they did not last long; later the quality of the erection was poor; and eventually he developed complete impotence. He does not get nocturnal erections.
How should this patient be managed?
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First choice now is sildenafil, tadalafil, or vardenafil |
