GU Board Review

Aric Bakshy, MD

Question 1 A 24 year old woman presents complaining of

dysuria, urgency, and frequency. She denies fever, vomiting, or back pain. She has no significant past medical history or medication allergies. She is ICON neg. UA shows +3 blood, + Nitrite, + Leukocyte esterase. What is the most appropriate course of action?

A. Urine culture and treat with abx 3 daysB. Urine culture and treat with abx 7 daysC. Treat with abx 3 daysD. Treat with abx 7 daysE. Wait for microscopic analysis of UA before next

step

Answer 1: C Treat with abx for 3 days! UTI most commonly dx bacterial infection Nitrite sensitivity 50%, specificity 90% Leukocyte Esterase sensitivity 48% and

specificity 85% Official UA has sensitivity of 60% If either test positive with clinical sx dx is

likely Negative UA does not r/o infection Pts without risk factors for complicated

UTI do NOT need cultures

The burning bean

Risk factors for complicated UTI-Pregnancy-DMrecurrent UTI-Recent indwelling catheter or

instrumentation-Structural abnormalities-Male sex-Extremes of age

The burning bean

Treatment of Uncomplicated UTI: 3 days tx; Bactrim, Fluoroquinalones

Pregnancy: Nitrofuantoin, Keflex

Complicated UTI: 7 days tx, culture

Question 2

A 56 year old man with DM 2 p/w fever for 3-4 days and groin pain. His exam appears as the image. What is the most appropriate initial management?

Question 2

A. High-Dose penicillinB. Hyperbaric oxygen therapyC. Pipercillin/TazobactamD. Suprapubic catheterizationE. Surgical Debreidment

Answer 2: C Pipercillin/TazobatamFournier's GangreneNecrotizing Fasciitis of penis and

scrotumTreatment is Abx and debridementRisk factors include DM, EtOHism, and

immunocompromisedUsually combination of aerobic and

anaerobic bacteriaEcoli, Bacteroides, Staph; Clostridium

possible if starting in colorectal region

Fourniers Gangrene

PEN- covers Gram + and Clostridium

Aminoglycoside or 3rd Gen Cephalosporin- covers Gram Negative

Clindamycin or Metronidazole- Covers anaerobes

Suprapubic cath may be needed, hyperbaric oxygen is an adjunct tx in some cases

Question 3

Which of the following statements regarding radiographic contrast-induced acute tubular necrosis is correct?

A. ACE-I, given orally pre-contrast can be protectiveB. Metformin can be protectiveC. N-Acetyl-L-cysteine given IV prior to contrast can

be protectiveD. Patients with DM are naturally protected from

contrast induced-nephropathy. E. Volume infusion at the time of contrast

administration increases the risk of renal injury.

Answer 3: Mucomyst!

Contrast Induced Nephropathy ATN is typically a reversible cause of renal

insufficiency Unk cause of contrast induced nephropathy,

thought to be due to obstruction by cases, cellular debris, and injury to peri-tubular capillaries

CIN defined as rise in Cr of 25% or incr by .5; may progress to oliguric ARF

Rise in Cr over 3 days; resolution within 2 weeks Most important risk factor is preexisting renal

Insufficiency (Cr > 1.4mg/dl) Risk Factors: DM, Multiple Myeloma, Age > 60, Large

vol contrast, volume depletion

To serve and protect the Bean! N-Acetyl-L-Cysteine Clinical studies on 2 days pre-treatment orally

prior to contrast load Statistical yet clinically unknown benefit to NAC

given in ED Prevention of Contrast-Induced Nephropathy

With Sodium Bicarbonate. Shavit et al.JAMA.2004; 292: 1428

(13.6%) infused with sodium chloride but in only 1 (1.7%) of those receiving sodium bicarbonate(mean difference, 11.9%; 95% confidence interval [CI], 2.6%-21.2%; P = .02).

Cheaper and more efficacious than ED provided NAC!

Question 4

66 y/o F on renal transplant list is rushed to the ER from HD because she is bleeding from her shunt when the catheter was removed. HR is 113, BP 98/54; in addition to direct pressure and calling vascular surgery, what is the most appropriate management?

A. Administer dexamethasone to stimulate platelet function

B. Administer enoxaparin to minimize clot aggregationC. Administer protamine sulfate to reverse heparin used

during HDD. Avoid IVF to preserve pts renal functionE. Give whole blood to match her volume loss

Answer 4: C Protamine SulfateShunt Complications-Arterial venous fistula most often with

radial artery and cephalic forearm vein-Arterialization of venous side in 3-5

weeks after surgery-Tunnel catheters (Quintin, Hickman)

used to bridge -Most common complication is

thrombosis of AVF- loss of thrill-Infection occurs in 2-5% of pts; Staph

Aureus most common

Shunt Complications

”Steal Syndrome”; vascular insufficiency distal to shunt p/w cold painful fingertips, dx w/ u/s

Shunt Bleeding: Usually controlled with direct pressure; when severe Protamine (.01mg/unit of heparin)

Platelet dysfunction can be augmented with Desmopressin(DDAVP) .3mg/kg- more important in massive GIB in renal failure

Blood transfusions may be necessary in pre-transplant pts- give wither CMV negative or leukocyte reduced blood

Question 5 A 27 y/o F on peritoneal dialysis p/w abd pain

and fever X 2 days. She noticed cloudy dialysate and she gave a sample of fluid to the nurse at triage. Her abdomen is normal on inspection but is tender diffusely with rebound. What is the most appropriate tx?

A. CT scan of abdomen with contrastB. Intraperitoneal first-gen cephalosporin or

vancomycinC. Intravenous first-gen cephalosporin of

vancomycinD. Laparotomy for removal of Tenckhoff catheterE. Placement of a Hickman catheter and emergent

HD

Answer 5: B IntraperitonealPeritoneal DialysisPD is most common form of dialysis

outside the USAPeritoneal membrane is the blood-

dialysate interface8L of dialysate per day given, 10 L

removedPeritonitis is most common

complicationDx based on >100 WBC, 50% pms, or

a positive gram stain

Peritoneal Dialysis

Most common bacteria are Staph-aureus, Staph-epi, Strep spp, and gram negatives

Tx is intraperitoneal loading dose of Cefazolin, vancomycin, or ceftazidime and outpt abx for 10-14 days

Abdominal wall hernia occurs in 10-20% of pts due to increased abd pressure

Question 6 Which of the following statements regarding

phosphorous metabolism is pts with ESRD is correct?

A. A low calcium-phosphate product indicates a high risk for systemic calcification

B. Prevention of systemic calcification includes oral calcium-binding gels and high phosphate dialysate

C. Symptoms of systemic calcification includes painful, swollen joints due to pseudogout

D. Systemic calcification affects only the small vessels of the extremities

E. These patients have reduced phosphate absorption and lower serum phosphate levels

Answer 6: C painful everythingSystemic Calcification in ESRDDecrease in phosphate excretion-

>increased serum PO4Phosphate binds serum calciumKidney fails to activate Vit DLow serum calcium stimulates PTH

release (secondary Hyperparathyroidism)

Calcium released from bone causes renal osteodystropthy and increased serum calcium-phophate binding

Systemic Calcification

Calcium-Phosphate Product (Ca X PO4)> 72

Swollen painful joints due to pseudogout (positive birefringent rhomboid crystals)

Small vessel calcification causing distal necrosis, esp finger tips, toes

Calcification of cardiac and pulm vasculature

Tx with phosphate binding medications, low calcium dialysate

Question 7

A 47 year old uncircumcised, obese male p/w painful tip of his penis. Physical exam reveals a swollen and tender glans and foreskin. On retraction the foreskin is excoriated, purulent, and there is a foul smelling discharge. This is limited to the glans. What is the diagnosis Dr?

A. BalanoposthitisB. Fourniers GangreneC. HSV infectionD. ParaphimosisE. Phymosis

Question 7: A Balanopothitis Inflamed Glans of

Penis! Usually inf; can be

dermatitis Skin flora, candida,

rarely G/C Tx with sitz bath,

gentle cleansing, first-gen cephalosporin

White cheesy typical of candida- use oral fluconazole or topical

Phimosis

Constriction of foreskin

Inability to retract over glans of penis

Leads to pain, inability to urinate

Steroid cream 4-6 weeks

Dilation, circumcision

Paraphimosis Inability to pull

foreskin (A)nterioly EMERGENCY Vascular compromise

and necrosis Flaccid penis with

distal engorgement Analgesia, ICE,

constant gentle traction

Puncture glans to allow edema out

Dorsal Slit

Question 8

A 32 year old man presents with a painful erection that has lasted 10 hours. Which of the following medications would most likely cause this condition?

A. OlanzapineB. PseudoephedrineC. TerbutalineD. TrazodoneE. Venlafaxine

Answer 8: D Priapus

-Greek minor God of fertility, protector of gardens, livestock, and male genitalia

-Son of aphrodite by dionysis, hermes, or adonis

-Punished for rape by having genitals replaced by large wooden ones

-Pompeii, House ofVettii

Priapism- Pathophysiology

PriapismPainful prolonged erectionHigh Flow- rare, due to traumatic

fistula between cavernosal artery and corpus cavernosum, non-painful, less risk ischemia, tx with embolisation

Low Flow- common, impaired venous outflow from corpus cavernosum

Priapism, etiology

Children- Sickle cell anemia, leukemia; vascular occlusion

Adults-Iatrogenic; hydralazine, prazosin, ccb, trazadone, chlorpromazine, other SSRI

Occasionally with sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis)

Priapism- Treatment

Dorsal penile nerve block, analgesiaHydration for sickle cellTertbutaline .25-.5mg SC to deltoid

q30 minPseudoephedrine 60-120mg po if

given early (low evidence)Cavernosal aspiration of blood with

instillation of saline + alpha-antagonist

Urology consult

Question 9 A 13 year old boy is brought to the ER for sudden

onset of groin pain. On examination his right testicle is swollen, raised, and tender. Which of the following statements regarding this pts condition is correct?

A. CT of the affected are is the imaging study of choice

B. Duplex ultrasonography provides little useful anatomic information

C. Positive creamasteric reflex confirms the diagnosisD. Relief of pain with elevation reliably differentiates

this condition from epididymitisE. The bell clapper deformity predisposes pts to this

condition

Answer E: Bell Clapper

Testicular TorsionPeak incidence age 13Time is Testis- 96% salvage in <4 hrs,

<10% if delayed 24 hours Testis descends through inguinal canal

taking with is peritoneal lining (Tunica Vaginalis)and fixes to posterior scrotum

Bell Clapper deformity results from Tunica Vaginalis connects to spermatic cord instead and allows testis to rotate freely.

Testicular Torsion

Presentation: Pain, swelling, loss of cremasteric reflex, no relief with elevation

Manual Detorsion- Open BookColor flow doppler U/S is 100%

specific and 80% sensitive for testicular torsion

Radionucleotide scintigraphy Urology consult

Epidiymitis

Gradual onset testicular/lower abdominal pain

Bacteria most common cause; >40 yrs G/C, >40 Ecoli

Viral infections (mumps)Prehns sign: elevation of scrotum

relieves pain a bitTx: Outpt for <40 y/o is 10 days of

doxycycline or ofloxacinTx: Outpt for >40 yrs is floroquinolone

or Bactrim

Question 10 Which of the following statements regarding

imaging techniques for evaluation of suspected kidney stones is correct?

A. CT scanning poses risk of nephrotoxic contrast

B. CT scanning provides little data about the adjacent intrabdominal structures

C. Intravenous pyelogram is highly sensitive but does not provide information on renal function

D. Plain radiography is highly specificE. Ultrasonography is the preferred modality for

pregnant pts but might not identify stones smaller than 5mm

Answer 10: E Ultrasound

Nephrolithiasis/Urolithiasis 7% of men and 3% woman age 20-50 RF: Dehydration, hot climates, fam hx, male,

gout, laxatives, HPTH, Crohns, Type 1 RTA Renal function, infectious Imaging required only for suspicion of high

grade obstruction, toxic appearance, first episode, questionable dx

CT Scan sensitive (97%) and specific (96%) for stones >1mm

Ultrasound less sensitive for stone <5mm but can assess for hydronephrosis (sensitive 85-95%, specific 100%)

Urolithiasis

IV pyelogram can assess renal function and and nearly as sensitive as CT

90% Stones are radiopaque90% of stones <5mm will pass within

4wks, 15% stones 5-8mm will passMost common site of impaction is

ureterovesicular junction; the lower the stone the more likely to pass

Treatment: Toradol + Morphine

Urolithiasis

Efficacy of alpha-blockers for the treatment of ureteral stones. Journal of Urology, 2007

Meta-analysis of 11 randomized studies, n=911

Alpha-blockers associated with 44% greater chance of spontaneous stone expulsion

Question 11

A 56 year old man reports intermittent, painless hematuria X 2 weeks. He is on coumadin for DVT tx, smokes. Physical exam is wnl. US shows TNTC RBC and 5 WBC/ HPF. Cr is 0.9 and Hgb is 14 and INR is 2.9. A CT scan of abdomen and pelvis is normal. What is the next step?

A. Administer 10mg Vit K B. Order U/S of l/e for DVTC. Rx 7 days cipro and d/c homeD. Reassure pt that he prob passed a stone

and just chillE. Refer pt to a urologist for cystoscopy

Answer 11: E Urologist

Hematuria 1ml of blood can make urine grossly

bloody and >5rbc/hpf warrants further w/u Age <20: Infections, glomerulonephritis Age 20-40: Kidney stone, UTI Age >40: Men= Bladder Ca, Women=UTI Blood only at beginning of stream likely

urethral source Blood at end bladder neck/prostate Blood throughout entire stream bladder,

ureter, kidney

Hematuria

Presence of casts, protein indicate likely renal pathology

80% of pts on anticoagulants who have hematuria have identifiable source

CT scan of the abdomen may show renal mass/ stone but is otherwise not necessary

Referral to urologist as outpt

Question 12

In the treatment of a 3 year old boy with a UTI, which of the following additional signs is the strongest indication for admission?

A. Localized myalgiasB. Maculopapular rashC. Marked feverD. Mucoid DiarrheaE. Persistent Vomiting

Answer 12: E, Vomiter

UTI in pediatric ptsNeonates- fever, irritable, poor

feeding, part of “r/o sepsis” w/uInfants/Toddler- Abdominal pain,

vomiting, enuresisSchool Kids- Typical adult sxOnly vomiting leading to inability

to take medication would result in hospitalization

Question 13 A 54 year old man presents with decreasing

urine output for over the past week. He has a h/o ESRD and underwent living donor transplant 3 months ago. Physical exam reveals BP of 150/100, minimal tenderness over transplant site. UA shows no infection. Current meds are Diltiazem, cyclosporine, azathioprine, prednisone. Normal cyclosporin levels would make this pts presentation c/w what?

A. Acute RejectionB. Cyclosporin-Induced NephropathyC. Development of post-surgical lymphoceleD. Renal Artery StenosisE. Tissue-invasive CMV infection

Answer 13: A- Acute RejectionRenal Transplant Pt Renal transplant failure 15-25% incidence in

first year Acute renal failure presents with decrease

urine output, worsening of HTN, and rise in Cr at 20% over baseline

Severe cases with tenderness over allograph, fever, leukocytosis

Renal Bx often needed for acute rejection v.s iatrogenic

Medications that inhibit C-P450 increase levels of cyclosporin, tacrolimius, sirolimus which are nephrotoxic- always call team!

Renal Transplant Patient

ER w/u includes UA, Culture, Drug Levels, CBC

Ultrasound of kidneys to r/o obstructive uropathy and compression from lymphocele or hematoma

Doppler study to assess for renal vein or artery (1st week) thrombosis

Renal artery stenosis occurs slowly and cause pre-renal azotemia

Renal Transplant Patient Post-Surgical lymphocele occurs in 1st 3 months in 5-15% pts Sx: pain over allograft, acute RF due to

compression of ureter, or iliac vein thrombosis/compression causing lower extremity swelling

CMV Infection 10-15% of renal transplant pts 1st-6 months Fever, elevated LFTs, pancytopenia May be tissue invasive with GI, Pulm, CNS

involvement

Question 14

A 45 year old man presents to the ER with low back pain X 2 weeks. He was seen in the ER one week ago and d/c'd with Motrin. On questioning he admits that he also has rectal pain. On exam he has a fever of 101.2 with a normal rectal vault but tender and boggy prostate. His urine shows >10 wbc/hpf but is Nitrite Neg. What is the best course of action?

A. Continue the motrin and d/c homeB. Urine culture, 28 day course of cipro , f/u urologyC. Urine culture, 14 day course of cipro, f/u urologyD. CT scan pelvis to r/o proctitisE. Urine culture, call back for results

Answer 14: B Culture and 28 days abx Prostatitis SubtypesAcute BacterialNon-bacterialChronic BacterialProctodynia

Many presentations; fevers, chills, dysuria, rectal pain, low back pain

In infectious types >10wbc/hpf

Prostatitis

Acute Bacterial80% Aerobic G- Bact (ecoli,

enterobacter, serratia, pseudomonas)

Age <35 consider C/GBoggy Tender prostateNo prostate massage-

bacteremia!Tx 14 days with fluoroquinolone

Prostatitis

Chronic Bacterial Ecoli (80%), Enterobacteriaceae,

enterococci, and P aeruginosa May have non-tender prostateCauses recurrent UTI’s in menMay present with obstructive sx;

hesitancy, incomplete voiding10-fold bacterial growth in the EPS;

100,000 CFU not needed28 day course Fluoroquinolone or Bactrim

Prostatitis

Prostodynia Not a true inflammation May be due to a primary voiding dysfunction May also have a psychological component Prazosin or diazepam with sitz baths. Tx: Consult urologyNon-bacterial Prostatitis C Trachomatis, Ureaplasma spp, M

tuberculosis, Coccidioides, Histoplasma, and Candida

Tx: Consult urology

Question 15 A 70 y/o unk male is BIBEMS for AMS. He is

lethargic, confused upon arousal, and has a pungent odor. Pt is afebrile. His BP is 70/60 and HR is 140, 100% on RA. He has JVD to his ear. Standard labs, EKG, and a cxr are ordered. His chemistry returns sig for a BUN of 120 and Cr of 10. He has a pun Hct of 38. He has no AVF or dialysis port. The nurse notes he just passed a large melanotic BM. Which of the following should not be considered in the initial w/u and management of the pt?

A. Airway managementB. Bedside cardiac ultrasoundC. DDAVP .3mg IV, Type and Cross 4 unitsD. Arrange for hemodialysisE. CT of the head

Answer 15- E CT head

Acute Renal Failure3 Major TypesPre-renal- Poor Cardiac Output,

HypotensionRenal- Renal parenchymal dzPost-renal- Obstruction past the

kidney･

Acute Renal Failure

DiagnosisFeNa = (urine Na/plasma Na)/(urine

creatinine/plasma creatinine) ･FeNa <1 % = Prerenal FeNa >1% = RenalDon’t forget the Foley!Creatinine 1.0 mg/dL - Normal GFR

Creatinine 2.0 mg/dL - 50% GFR Creatinine 4.0 mg/dL - 75% GFR

Creatinine 8.0 mg/dL - 95% GFR

Acute Renal Failure

ComplicationsCardiovascular: Hypotension/ Vol

OverloadUremia: Encephlopathy,

Pericardial Effusion/TamponadeHeme: Anemia, Platelet

DysfunctionElectrolytes: Hyperkalemia,

HypocalcemiaPulm: Pulmonary Edema

Acute Renal Failure

Indications for Emergent DialysisVolume overloadHyperkalemia (K+ >6.5 or rising)Acid-base imbalanceSymptomatic uremia (pericarditis,

encephalopathy, bleeding dyscrasia, nausea, vomiting, pruritus)

Uremia (BUN>100)Dialyzable intoxications: methanol, ethylene

glycol, theophylline, aspirin, lithium

THE END!