Genitourinary Disorders II

Fibromuscular dysplasia accounts for less than 10% of cases of RAS, results from an abnormality in the lining of the renal artery in which fibrous tissue forms and narrows the vessel, occurs in patients between 25 and 50 years of age, and occurs mostly in women (90%) (Langley & Talley, 2021, p. 685).

The onset of hypertension at a younger age than 30 years or an older age than 55 years is one of the circumstances in which RAS should be considered, and an epigastric or renal artery bruit supports the diagnosis (Langley & Talley, 2021, p. 686).

Choice a is wrong because atherosclerosis leads to more than 90% of all cases of RAS and is typically seen in men older than 45 years and women older than 55 years who have risk factors such as hypertension, high cholesterol levels, insulin resistance, smoking, and obesity (Langley & Talley, 2021, p. 685).

Choice c is wrong because vasculitis such as Takayasu arteritis is a recognized but uncommon etiology of RAS, and it does not fit the demographic and examination pattern described in this patient (Langley & Talley, 2021, p. 684).

Choice d is wrong because thromboembolic disease is a listed etiology of RAS, although it typically produces acute renal infarction rather than the gradual onset of hypertension with an epigastric bruit described here (Langley & Talley, 2021, p. 684).

A decline in estimated GFR by greater than 30% from baseline renal function after the initiation of an ACE inhibitor or an angiotensin receptor blocker is one of the circumstances in which RAS should be considered (Langley & Talley, 2021, p. 686).

Resistant hypertension that was previously well controlled and has become difficult to treat despite the use of three or more blood pressure medications is also characteristic of RAS (Langley & Talley, 2021, p. 686).

Choice b is wrong because a favorable response to a thiazide diuretic does not suggest RAS; diuretics are secondary options for blood pressure control in RAS rather than diagnostic findings (Langley & Talley, 2021, pp. 686, 689).

Choice c is wrong because the absence of a family history of hypertension raises suspicion for RAS, whereas a strong family history points toward essential hypertension (Langley & Talley, 2021, p. 686).

Choice d is wrong because hypokalemia, not hyperkalemia, occurs from activation of the renin-angiotensin-aldosterone system in response to decreased blood flow to the kidney, and RAS is associated with metabolic acidosis rather than metabolic alkalosis (Langley & Talley, 2021, p. 686).

Intra-arterial digital subtraction angiography is the definitive diagnostic test for RAS and is currently the gold standard, and carbon dioxide subtraction angiography can be used in place of contrast dye to reduce the risk of contrast-induced nephropathy (Langley & Talley, 2021, p. 687).

The most direct measure of the hemodynamic or functional significance of a stenosis is the differential pressure across the stenosis, and renal artery pressure can be measured during catheterization and used to guide treatment (Langley & Talley, 2021, p. 687).

Choice a is wrong because CTA carries a risk of contrast-induced nephropathy and requires more contrast medium than renal angiography, which is a disadvantage in a patient with an estimated GFR of 22 ml/min (Langley & Talley, 2021, p. 687).

Choice b is wrong because MRA uses gadolinium-based contrast medium that must be avoided in patients with moderate or end-stage renal failure, and MRI or MRA cannot be used in patients with many implanted devices, including previous renal stents, so in-stent restenosis cannot be evaluated (Langley & Talley, 2021, p. 687).

Choice c is wrong because Doppler ultrasonography may be used for initial diagnostic screening, but an invasive diagnostic test may be required when the stenosis is critical, and its results are highly dependent on patient habitus, cooperation, and the skill of the technician performing the examination (Langley & Talley, 2021, pp. 686–687).

Revascularization is recommended by the American Heart Association when the renal artery is reduced by more than 70% of its diameter, along with uncontrolled hypertension on three agents, one of which is a diuretic (Langley & Talley, 2021, p. 690).

Revascularization may also be indicated for 50% to 70% stenosis when a significant hemodynamic gradient is present across the stenosis (Langley & Talley, 2021, p. 690).

Choice b is wrong because vasodilating agents such as minoxidil are reserved for patients who are unresponsive to all other agents, and referral to a hypertension specialist would be prudent before such therapy is started (Langley & Talley, 2021, p. 689).

Choice c is wrong because continued medical management alone would delay intervention in a patient who meets criteria for revascularization, and observation does not address the progressive loss of renal function caused by the stenosis (Langley & Talley, 2021, p. 690).

Choice d is wrong because surgical procedures are recommended for complex renal artery stenosis only, and percutaneous transluminal renal angioplasty with stent placement precedes surgical reconstruction in the treatment sequence (Langley & Talley, 2021, pp. 689–690).

Struvite calculi are composed of magnesium-ammonium-phosphate, are commonly seen in women with recurrent urinary tract infections, are most often large and cause obstruction and bleeding, are radiodense, and are associated with an alkalotic urinary pH greater than 7 to 7.5 (Couture, 2021, p. 696).

Struvite calculi are caused by urease-producing organisms such as Proteus species, Haemophilus species, Klebsiella species, and Ureaplasma urealyticum (Couture, 2021, p. 696).

Choice a is wrong because calcium oxalate calculi are the most common type, accounting for approximately 80% of renal calculi, and they are not specifically associated with recurrent urinary tract infection in the presence of a markedly alkaline urine pH (Couture, 2021, pp. 694, 696).

Choice b is wrong because uric acid calculi are frequently associated with urinary pH levels lower than 5.5, with an average urinary pH level of 5.85 (Couture, 2021, p. 695).

Choice d is wrong because cystine calculi result from the abnormal excretion of cystine, ornithine, lysine, and arginine, and cystine is the only amino acid that becomes insoluble in urine; they are not caused by urease-producing organisms (Couture, 2021, p. 696).

Renal ultrasonography involves no radiation, may be used as the initial test versus CT scan, and has not been shown to increase adverse outcomes or events when compared with CT scan (Couture, 2021, p. 696).

Every effort should be made to minimize ionizing radiation exposure to the fetus during pregnancy, and ultrasonography is the imaging modality of choice (Gantioque, 2026, slide 22).

Choice a is wrong because, although noncontrast helical CT is the gold standard radiographic test for diagnosing nephrolithiasis, it involves ionizing radiation and is not the initial study of choice during pregnancy (Couture, 2021, p. 696).

Choice c is wrong because an excretory or retrograde pyelogram permits the exact definition of stones and reveals the presence or absence of obstruction, but it requires contrast administration and is not the initial study of choice in pregnancy (Couture, 2021, p. 696).

Choice d is wrong because plain films of the abdomen reveal only opaque calculi and provide less information about obstruction than ultrasonography does (Couture, 2021, p. 696).

When flank pain increases in intensity and radiates downward to the groin, this indicates that the stone has passed to the lower third of the ureter (Couture, 2021, p. 696).

Acute flank pain associated with nephrolithiasis is colic-like, and the pain is not relieved by position (Couture, 2021, p. 696).

Choice b is wrong because frequency, urgency, and dysuria suggest that the stone is located in the portion of the ureter within the bladder wall, and this patient denies those symptoms (Couture, 2021, p. 696).

Choice c is wrong because oliguria and acute renal failure may occur when both collecting systems are obstructed by stones, which would present with reduced urine output rather than isolated radiating flank pain (Couture, 2021, p. 696).

Choice d is wrong because a stone that has passed into the bladder would be expected to relieve the obstruction and the colicky pain, whereas pain that radiates to the groin indicates that the stone remains in the lower ureter (Couture, 2021, p. 696).

Treatment of struvite calculi requires eradicating the infection with antibiotics and the use of interventional techniques, and surgical intervention should be considered especially for stones larger than 10 mm or when there is evidence of ongoing obstruction or infection (Couture, 2021, pp. 696, 701).

Struvite stones are soft and amenable to percutaneous nephrolithotomy or extracorporeal shock wave lithotripsy (Couture, 2021, p. 696).

Choice a is wrong because antibiotics alone eliminate the infection but do not remove the stone, which continues to serve as a nidus for urease-producing organisms (Couture, 2021, pp. 696, 701).

Choice c is wrong because medical expulsive therapy with an α-blocker or a calcium channel blocker is offered to patients with stones up to 10 mm who are eligible for observation, and this stone measures 14 mm (Couture, 2021, p. 697).

Choice d is wrong because struvite stones are commonly large and cause obstruction and bleeding rather than passing spontaneously, so observation would allow progressive obstruction and infection (Couture, 2021, p. 696).

AUR is defined as the sudden inability to void spontaneously, and it occurs most frequently in men older than 60 years; the most common cause of AUR in the emergency department is BPH (Gantioque, 2026, slide 27).

Choice b is wrong because urethral stricture is an anatomic cause of AUR and is a less common etiology than BPH in this population (Gantioque, 2026, slides 27–28).

Choice c is wrong because obstruction related to spinal cord compression is an indication for admission when it causes AUR, but it is not the most common cause (Gantioque, 2026, slides 29, 37).

Choice d is wrong because anticholinergic medications are a pharmacologic cause of AUR through decreased bladder muscle contraction, although BPH remains the most common cause in the emergency department (Gantioque, 2026, slides 27, 29).

Prompt bladder decompression begins with placement of a 14F to 18F urinary catheter, and when a catheter cannot be passed in a man with no prior instrumentation, a 20F to 22F catheter with a coudé tip may be considered (Gantioque, 2026, slide 33).

If a catheter cannot be passed, either suprapubic aspiration as a temporizing measure or placement of a suprapubic catheter is indicated (Gantioque, 2026, slide 33).

Choice b is wrong because downsizing to a 10F to 12F catheter is recommended when a 14F to 18F catheter cannot be passed in a patient with a history of a prior transurethral procedure or a known stricture, neither of which this patient has (Gantioque, 2026, slide 33).

Choice c is wrong because suprapubic aspiration or catheter placement is reserved for patients in whom catheterization has failed after appropriate attempts, including the use of a larger coudé-tip catheter (Gantioque, 2026, slide 33).

Choice d is wrong because deferring catheterization until a retrograde urethrogram is obtained applies to the trauma patient suspected of having a urethral injury, which is suggested by gross hematuria, a high-riding prostate on rectal examination, or blood at the meatus (Gantioque, 2026, slide 33).

Postobstructive diuresis can be a complication of AUR in the catheterized patient, and it is probably best to observe the patient for 2 to 3 hr after bladder decompression to ensure that a postobstructive diuresis does not cause clinical deterioration (Gantioque, 2026, slide 35).

It is generally now felt that rapid bladder decompression is safe provided that supportive care is available if hypotension develops (Gantioque, 2026, slide 35).

Choice b is wrong because no randomized trials have compared rapid with intermittent bladder decompression, and rapid decompression is generally considered safe when supportive care is available (Gantioque, 2026, slide 35).

Choice c is wrong because prophylactic antibiotics are not indicated for patients with an indwelling urinary catheter who have no evidence of infection (Gantioque, 2026, slide 35).

Choice d is wrong because the patient requires observation for postobstructive diuresis, and admission is indicated when significant postobstructive diuresis requires intravenous fluids or pressors (Gantioque, 2026, slides 35, 37).

Catheterization should be deferred in the trauma patient suspected of having a urethral injury, as indicated by gross hematuria, a high-riding prostate on rectal examination, or blood at the meatus, until a retrograde urethrogram has been done (Gantioque, 2026, slide 33).

Choice a is wrong because catheterization is deferred in this patient until a retrograde urethrogram has been performed, and evaluation for urethral injury must precede any attempt to pass a catheter (Gantioque, 2026, slide 33).

Choice c is wrong because suprapubic aspiration is a temporizing measure used when a catheter cannot be passed in a patient with AUR, rather than the initial intervention in suspected urethral trauma (Gantioque, 2026, slide 33).

Choice d is wrong because a postvoid residual measurement is used to evaluate incomplete bladder emptying, with more than 200 mL usually considered abnormal, and it does not address the suspected urethral injury (Gantioque, 2026, slide 32).

On DRE, the prostate may be enlarged, and size does not correlate with the severity of symptoms or with the degree of obstruction (Roberg, 2021, p. 674).

The prostate should feel smooth and rubbery, and focal enlargement, nodularity, or extreme hardness may represent malignancy, for which further investigation with transrectal ultrasound and biopsy is indicated (Roberg, 2021, p. 674).

Choice a is wrong because prostate size on DRE does not correlate with the severity of symptoms (Roberg, 2021, p. 674).

Choice b is wrong because prostate size on DRE does not correlate with the degree of obstruction (Roberg, 2021, p. 674).

Choice d is wrong because the initial evaluation also includes urinalysis, a urine culture when irritative symptoms are present, blood urea nitrogen and creatinine to assess for renal insufficiency, and often prostate-specific antigen, along with symptom scoring using the International Prostate Symptom Score (Roberg, 2021, pp. 674–675).

Medications that can worsen symptoms include decongestants, diuretics, and other sympathomimetics, which act on α receptors to enhance prostate muscle tone and thereby increase dynamic obstruction (Roberg, 2021, p. 675).

Anticholinergics such as antihistamines, bowel antispasmodics, tricyclic antidepressants, opiates, and antipsychotics decrease bladder muscle contraction and thereby increase urine retention (Roberg, 2021, p. 676).

Choice b is wrong because the mechanisms are reversed: diphenhydramine is an antihistamine with anticholinergic effects that decreases bladder muscle contraction, and pseudoephedrine is a sympathomimetic that enhances prostate muscle tone (Roberg, 2021, pp. 675–676).

Choice c is wrong because these agents increase obstruction and retention rather than relaxing the internal urethral sphincter, and it is the α blockers rather than the sympathomimetics that relax muscle fibers in the prostate gland and capsule and in the internal urethral sphincter (Roberg, 2021, pp. 675–676).

Choice d is wrong because both medications are recognized contributors to worsening symptoms, and a thorough medication review is part of the management of benign prostatic hyperplasia (Roberg, 2021, pp. 675–676).

Finasteride is a 5-alpha reductase inhibitor that blocks the conversion of testosterone to dihydrotestosterone, works on the epithelial component of the prostate, and results in reduction in the size of the gland and improvement in symptoms, and 6 months of therapy is required for maximal effect (Roberg, 2021, p. 676).

Choice b is wrong because dutasteride 0.5 mg once a day is another 5-alpha reductase inhibitor with the same mechanism and class effect, and a more rapid onset of benefit is not described (Roberg, 2021, p. 676).

Choice c is wrong because phosphodiesterase 5 inhibitors such as tadalafil 5 mg daily are used for patients with benign prostatic hyperplasia and erectile dysfunction or for lower urinary tract symptoms that are not responsive to an α-adrenergic antagonist, not because finasteride lacks efficacy (Roberg, 2021, p. 676).

Choice d is wrong because surgery may be necessary when significant urinary symptoms exist, and an adequate trial of medical therapy has not yet been completed in this patient (Roberg, 2021, pp. 676–677).

Open simple prostatectomy is reserved for patients with a very large prostate, accompanying bladder stones, bladder diverticula, or an inability to be positioned for transurethral surgery (Roberg, 2021, pp. 677–678).

Choice a is wrong because TURP is a standard transurethral approach, but open simple prostatectomy is specifically indicated when a very large prostate is accompanied by bladder stones (Roberg, 2021, pp. 677–678).

Choice b is wrong because TUIP resects no tissue, is usually performed as an outpatient procedure, and may benefit patients with benign prostatic hyperplasia associated with smaller prostate glands, especially younger men (Roberg, 2021, p. 678).

Choice d is wrong because urethral stents may be used for patients who are not candidates for standard surgery and are preferred to chronic catheterization or suprapubic cystostomy, whereas this patient is a surgical candidate (Roberg, 2021, p. 679).

Penile shaft fracture is a traumatic rupture of the corpus cavernosum and the encompassing tunica albuginea, and hematoma formation occurs at the rupture site (Gantioque, 2026, slide 48).

During erection, pressure within the corpus cavernosum is maximal and close to arterial pressure, increasing the volume in each corpus to maximum, which thins the tunica albuginea and makes it susceptible to rupture (Gantioque, 2026, slide 48).

Choice a is wrong because a penile fracture may involve the corpus spongiosum, but the primary injury is rupture of the corpus cavernosum and its encompassing tunica albuginea (Gantioque, 2026, slide 48).

Choice c is wrong because 25% to 30% of patients have an associated urethral injury, which may be partial or complete, but urethral injury alone does not explain the immediate detumescence and hematoma formation (Gantioque, 2026, slide 48).

Choice d is wrong because the suspensory ligament is not the structure that ruptures; the injury is a rupture of the tunica albuginea, and the most common fracture site is the proximal shaft of the penis (Gantioque, 2026, slide 48).

Blood at the tip of the penis or frank hematuria suggests an associated urethral injury, and blood at the urethral meatus may be present when a urethral injury has occurred (Gantioque, 2026, slides 50, 52).

Choice a is wrong because deviation of the penis away from the side of injury reflects the site of the tunical tear in the corpus cavernosum rather than urethral involvement (Gantioque, 2026, slides 50, 52).

Choice c is wrong because a palpable defect in the penile shaft indicates the site of the tunical tear and does not specifically indicate urethral injury (Gantioque, 2026, slide 52).

Choice d is wrong because ecchymosis may extend to involve the scrotum as a result of hematoma spread and is not specific for urethral injury (Gantioque, 2026, slide 52).

Retrograde urethrography is recommended in all cases of suspected urethral trauma and should be done with low pressure during injection and before urethral catheterization (Gantioque, 2026, slide 54).

Urethral catheterization is performed in all cases after excluding urethral trauma (Gantioque, 2026, slide 55).

Choice b is wrong because cavernosography may be needed to confirm the diagnosis and the site of the tear, but it does not evaluate urethral integrity, and diagnostic exploration is recommended when cavernosography is negative but clinical suspicion of a fracture is high (Gantioque, 2026, slide 54).

Choice c is wrong because MRI of the penis may be needed to confirm the diagnosis and the site of the tear, but it does not assess the urethra, which is the question being addressed before catheterization (Gantioque, 2026, slide 54).

Choice d is wrong because ultrasonography may be done to confirm a suspected tear of the tunica albuginea, but it does not evaluate the urethra (Gantioque, 2026, slide 54).

All patients with penile fracture must be hospitalized for prompt surgery, and urologic evaluation and early surgical treatment are essential to prevent complications such as erectile dysfunction, impotence, penile deformity, and urethral stricture (Gantioque, 2026, slides 55–56).

Delay in seeking treatment is the major cause of morbidity, and early surgical repair is important (Gantioque, 2026, slide 56).

Choice a is wrong because discharge with conservative management delays the surgical repair that is required, and delay in treatment is the major cause of morbidity (Gantioque, 2026, slides 55–56).

Choice c is wrong because prophylactic antibiotic use is unnecessary, and observation without surgery does not restore the normal shape of the penis or preserve sexual and urinary function (Gantioque, 2026, slide 55).

Choice d is wrong because ice packs and splinting of the penis with a tongue blade are local measures used to reduce hemorrhage in the emergency department, not definitive management, and all patients require hospitalization for prompt surgery (Gantioque, 2026, slides 55–56).