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27 Cards in this Set

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A 14 year old boy presents in the Emergency Room 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

Diagnosis
Management
Diagnosis: Testicular torsion

Management: Emergency surgery
A 24 year old man presents in the emergency room with very severe pain of recent onset in his right scrotal contents. There is fever of 103  and pyuria. The testis is in the normal position, and it appears to be swollen and exquisitely painful. The cord is also very tender.

Diagnosis
Management
Diagnosis: Acute Epididimitis

Management: This is the condition that presents the differential diagnosis with testicular torsion. Torsion is a surgical emergency. Epididimitis is not. Don’t rush this guy to the OR, all he needs is antibiotic therapy. If the vignette is not clear-cut, i.e: and adolescent that looks like epidimitis, but could be torsion, pick a sonogram to rule out torsion before you choose the non-surgical option.
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 and flank pain.

Diagnosis
Management
Diagnosis: UTI with obstruction

Management: IV antibiotics and possible stenting or nephrostomy; stone exraction in a septic patient is hazardous
An adult female relates that five days ago she began to notice frequent, painful urination, with small volumes of cloudy and malodorous urine. For the first three days she had no fever, but for the past two days she has been having chills, high fever, nausea and vomiting. Also in the past two days she has had pain in the right flank. She has had no treatment whatsoever up to this time.

Diagnosis
Management
Diagnosis: Acute Pyelonephritis

Management: Hospitalization, IV Abx; U/S to rule out obstruction; Men and children should not be getting frequent UTIs while in women its fairly common because of the different anatomy
A 62 year old male presents with chills, fever, dysuria, urinary frequency, diffuse low back pain and an exquisitely tender prostate on rectal exam.

Diagnosis
Management
Diagnosis: Acute prostatitis

Management: IV antibiotics; do not do any more rectal exams (for fun) or prostate massages (for business) because it could lead to septic shock
You receive a call from a patient at 3:00 AM. His regular urologist retired five years ago, and he has not sought a replacement. At about 11:00 PM last night, the patient injected himself with papaverine directly into the corpora, as he had been instructed to do for his chronic, organic impotence. He achieved a satisfactory erection and had intercourse, but the erection has not gone away and he still has it at this time.

Diagnosis
Management
Diagnosis: Iatrogenic Priapism

Management: Emergency. Injection with an alpha agonist (phenylephrine, epinephrine, terbuatline)
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.

Diagnosis
Management
Diagnosis: Posterior Urethral Valves

Management: Urinary Cath if it passes; Voiding cystourethrogram
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 his penis, about mid-way down the shaft.

Diagnosis
Management
Diagnosis: Hypospadias

Management: Don't do the circumcision; the foreskin may be needed when reconstruction occurs
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

Diagnosis
Management
Diagnosis: Hematuria from the trivial trauma in kids means congenital anomaly of some sort.

Management: Start with sonogram; IVP may be needed later
A 9 year old boy gives a history of three days of burning on urination, with frequency, low abdominal and perineal pain, left flank pain and fever and chills for the past two days.

Diagnosis
Management
Diagnosis: Little kids don't get UTIs so be suspicious of a congential anomaly

Management: Treat with antibiotics but start looking for the congenital cause of this
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, voids normally and at appropriate intervals, but also happens to be wet with urine all the time.

Diagnosis
Management
Diagnosis: low implantation of one ureter. In little boys there would be no symptoms, because low implantation in boys is still above the sphincter, but in little girls the low ureter empties into the vagina and has no sphincter. The other ureter is normally implanted and accounts for her normal voiding patter.

Management: the vignette did not include physical exam, that would be the next step, which might show the abnormal ureteral opening. Often physical exam does not reveal the anomaly, and imaging studies would be required (start with IVP). Surgical repair will follow.
A 16 year old boy sneaks out with his older brother’s friends, and goes on a beer-drinking binge for the first time in his life. He shortly thereafter develops colicky flank pain

Diagnosis
Management
Diagnosis: Ureteropelvic Junction Obstruction

Management: Start with U/S; Repair will follow
A 62 year old male known to have normal renal function reports an episode of gross, painless hematuria. Further questioning determines that the patient has total hematuria rather than initial or terminal hematuria

Diagnosis
Management
Diagnosis: The bleeding can be occurring anywhere between the kidneys and the bladder; but not the prostate or urethra

Management: Start with an IVP and then a cystoscopy
70 year old man is referred for evaluation because of a triad hematuria, flank pain and a flank mass. He also has hypercalcemia, erythrocytosis and elevated liver enzymes.

Diagnosis
Management
Diagnosis: Most likely renal cell carcinoma

Management: IVP first and CT scan next would be the standard sequence. In real life, if a urologist saw a patient with a palpable flank mass, he or she might go straight for the CT scan. Hopefully they will offer you one or the other, and not force you to choose between the two.
A 61 year old man presents with a history of hematuria. Intravenous pyelogram shows a renal mass, and sonogram shows it to be solid rather than cystic. CT scan shows a heterogenic, solid tumor.

Diagnosis
ManagemA 61 year old man presents with a history of hematuria. Intravenous pyelogram shows a renal mass, and sonogram shows it to be solid rather than cystic. CT scan shows a heterogenic, solid tumor.

Diagnosis
Renal Cell Carcinoma
A 55 year old, chronic smoker, reports three instances in the past two weeks when he has had painless, gross, total hematuria. In the past two months he has been treated twice for irritative voiding symptoms, but has not been febrile and urinary cultures have been negative.

Diagnosis
Management
Diagnosis: Most likely bladder cancer

Management: IVP and cystoscopy
A 59 year old black man has a rock-hard, discrete, 1.5 cm. nodule felt in his prostate during a routine physical examination.

Diagnosis
Management
Diagnosis: Prostate Cancer

Management: Trans-rectal biopsy; Eventually resection will be needed
An 82 year old gentleman who has congestive heart failure and chronic obstructive pulmonary disease is told by his primary care physician that his level of prostatic specific antigen (PSA) is abnormally high. The gentleman has seen ads in the paper for sonographic examinations of the prostate, and he has one done. The examination reveals a prostatic nodule, which on trans-rectal biopsy is proven to be carcinoma of the prostate. The man is completely asymptomatic as far as this cancer is concerned. He has not evidence of metastasis either.

Management
This man should not have had the PSA done in the first place after age 75
A 25 year old man presents with a painless, hard testicular mass.

Diagnosis
Management
Diagnosis: Testicular Cancer

Management: This will sound horrible, but here is a disease where we shoot to kill first…and ask questions later. The diagnosis is made by performing a radical orchiectomy by the inguinal route. That irreversible, drastic step is justified because testicular tumors are almost never benign. Beware of the option to do a trans-scrotal biopsy: that is a definitive no-no. further treatment will include lymph node dissection in some cases (too complicated a decision for you to know about) and platinum-based chemotherapy. Serum markers are useful for follow up: alfa-fetoprotein and beta-HCG, and they have to be drawn before the orchiectomy (but they do not determine the need for the diagnostic orchiectomy, that still needs to be done).
A 25 year old man is found on a pre-employment chest X-Ray to have what appears to be a pulmonary metastasis from an unknown primary tumor. Subsequent physical examination discloses a hard testicular mass, and the patient indicates that for the past six months he has been losing weight for no obvious reason.

Management
This is testicular cancer with mets. The point is to understand testicular cancer responds greatly to chemotherapy and should be given regardless of the stage
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 can not. On physical exam his bladder is palpable half way u 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 four or five times a night to urinate. Because of a cold, two days ago he began taking anthihystaminics, using “nasal drops”, and drinking plenty of fluids.

Diagnosis
Management
Diagnosis: Acute urinary retention with underlying benign prostatic hypertrophy

Management: Indwelling bladder catheter. Alpha-blockers
On the second post-operative day after surgery for repair of bilateral inguinal hernias, the patient reports that he “can not hold his urine”. Further questioning reveals that every few minutes he urinates a few cc’s of urine. On physical examination there is a large palpable mass arising from the pelvis and reaching almost to the umbilicus

Diagnosis
Management
Diagnosis: Acute urinary retention with overflow incontinence

Management: Indwelling bladder catheter
A 42 year old lady consults you for urinary incontinence. She is the mother of five children and ever since the birth of the last one, seven 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.

Diagnosis
Management
Diagnosis: Stress incontinence

Management: Surgical Repair of the pelvic floor
A 72 year old man who in previous years has passed a total of three urinary stones is now again having symptoms of ureteral colic. He has relatively mild pain that began six hours ago, and does not have much in the way of nausea and vomiting. X-Rays show a 3mm ureteral stone just proximal to the ureterovesical junction

Diagnosis
Management
Diagnosis: Kidney stone

Management: Sounds like a small stones. Keep the lasers, sonic waves, photon beams, ninja swords on hold. Just wait for it to pass. Give pain meds and fluids to help out
54 year old lady has a severe ureteral colic. IVP shows a 7mm. Ureteral stone at the ureteropelvic junction.

Diagnosis
Management
Diagnosis: A big stone that won't pass

Management: Best option is shock-wave-lithrotripsy
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.

Management
The first part of this vignette sounds like prostatitis, which would be common and not particularly challenging; but if the prostate is normal on exam the ante is raised: The point of the vignette becomes that men (particularly young ones) are not supposed to get urinary tract infections. This infection needs to be treated, so ask for urinary cultures and start antibiotics…but also start a urological work-up. Do not start with cystoscopy (do not instrument an infected bladder, you could trigger septic shock). Start with either IVP (always a traditional way to begin a urological work-up), or sonogram (which is also a pretty safe thing to do on anybody under any circumstances).
A 72 year old man consults you with a history for 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.

Diagnosis
Management
Diagnosis: Pneumaturia due to a fistula between teh bowel and the bladder

Management: Intuitively you would think that either cystoscopy or sigmoidoscopy would verify the diagnosis, but real life does not work that way: they seldom show anything. Contrast studies (cystogram or barium enema) are also typically unrewarding. The test to get is CT scan. Because ruling out cancer of the sigmoid is important, the sigmoidoscopic exam would be done at some point, but not as the first test. Eventually surgery will be needed