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Physiology, Trauma&Fistula, Sexual Dysfunction, Urinary Divergence

Sodium reabsorption in the proximal tubule:
A) results in a hypotonic tubular fluid.
B) occurs against a steep concentration gradient.
C) is accompanied by bicarbonate excretion.
D) occurs by an active transport mechanism.
E) is regulated by aldosterone.

D (occurs by an active transport mechanism.About two-thirds of the glomerular ultrafiltrate is reabsorbed in the proximal tubule with little change in the osmolality or sodium concentration of the unreabsorbed fraction. In other words, fluid reabsorption in the proximal tubule is nearly isosmotic and is coupled to the active transport of sodium. Since chloride and bicarbonate are the primary anions in the extracellular fluid, most of the filtered sodium is reabsorbed with these anions. Because of the high water permeability of the proximal tubule, sodium transport occurs against a minimal concentration gradient. Aldosterone regulates sodium-potassium exchange in the collecting duct.Shoskes DA, McMahon AW: Renal physiology and pathophysiology, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 2, chap 38, pp 1032-1033. AdultPhysiology, Immunology, & Adrenal )

The production of sex hormone binding globulin (SHBG) is increased by:
A) hypothyroidism.
B) hyperthyroidism.
C) insulin.
D) nephrotic syndrome.
E) progestins.

B (hyperthyroidism.Sexual dysfunction and infertility can on rare occasions be caused by thyroid dysfunction. Hyperthyroidism/thyrotoxicosis can elevate the serum levels of sex hormone binding globulin (SHBG) and subsequently lower circulating free testosterone. Hypothyroidism can have the opposite effect (lower SHBG) as can insulin administration, glucocorticoid excess, hepatic disease and nephrotic syndrome. Estrogen can increase SHBG production and progestins can lower it.Sabanegh E, Agarwal A: Male infertility, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 21, p 627. AdultPhysiology, Immunology, & Adrenal )

"A 45-year-old woman undergoes a left adrenalectomy for pheochromocytoma. Three months later, she still has sustained hypertension. The next step is: "
A) plasma renin activity.
B) plasma free metanephrine levels.
C) 24-hour urinary cortisol levels.
D) abdominal MRI scan.
E) MIBG scan.

B (plasma free metanephrine levels.Repeat metabolic testing should be performed after adrenalectomy to document normalization of chromaffin cell function. One of the pitfalls of diagnosing and treating pheochromocytoma is failure to recognize multiple lesions at the time of treatment. It has been estimated that between 10-20% of pheochromocytomas are malignant or multifocal. In a patient who undergoes surgical resection of an adrenal pheochromocytoma but still has persistent unexplained hypertension two to three months after the procedure, residual tumor somewhere else in the body must be considered. While MIBG scan may be helpful in identifying the location of this lesion, the patient should initially have plasma free metanephrine levels measured. If this is normal MIBG scan is not indicated. Similarly, MRI should not be ordered until pheochromocytoma is ruled in or out using less invasive diagnostic testing. Clinical suspicion of primary hyperaldosteronism or Cushing's syndrome is low in this case, so plasma renin activity and 24-hour urinary cortisol levels will not be helpful.Kutikov A, Crispen PL, Uzzo RG: Pathophysiology, evaluation, and medical management of adrenal disorders, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 2, chap 57, pp 1710-1711. AdultPhysiology, Immunology, & Adrenal )

The nephrotoxic effect of cisplatin is due to:
A) efferent arteriolar constriction.
B) afferent arteriolar constriction.
C) pre-existing plasma volume contraction.
D) a direct toxic effect on renal tubular cells.
E) renal tubular obstruction from drug precipitation.

D (a direct toxic effect on renal tubular cells.Cisplatin nephrotoxicity is due to a direct toxic effect of the drug on renal tubular cells. Azotemia and dehydration are predisposing conditions which increase the risk of this complication. Cisplatin is not precipitated in the renal tubules nor does it affect glomerular hemodynamics. Goldfarb DA, Poggio ED: Etiology, pathogenesis, and management of renal failure, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 2, chap 43, pp 1197-1198. GeneralPhysiology, Immunology, & Adrenal )

Normal bladder compliance during physiologic filling is primarily due to:
A) autonomic nerve activity.
B) circulating hormones.
C) cholinergic receptor activity.
D) local secretion of nitric oxide.
E) bladder wall viscoelasticity.

E (bladder wall viscoelasticity.The main determinants of compliance are the elastic and viscoelastic properties of the bladder. When these are destroyed as in fibrosis of the bladder, poor compliance results. Neurogenic influences may be operative in late stages of filling. Bladder smooth muscle maintains a steady level of contractility and tone that is dependent on the activity in the autonomic nerves, circulating hormones, local metabolites, locally secreted agents such as nitric oxide, and temperature.Wein AJ, Dmochowski RR: Neuromuscular dysfunction of the lower urinary tract, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 3, chap 65, pp 1909-1912. GeneralPhysiology, Immunology, & Adrenal )

"In the management of advanced urologic malignancies, stimulation of T cells by dendritic cells: "
A) is restricted to the Class I MHC (major histocompatibility complex).
B) causes T cell differentiation into plasma cells.
C) is suppressed by TNF (tumor necrosis factor).
D) is augmented by blockade of the T cell receptor.
E) produces interleukins.

E (produces interleukins.An integral part of the immune response involves the activation of T cells by dendritic or antigen presenting cells. This interaction occurs via the T cell receptor in the context of MHC (major histocompatibility complex) class II molecules. B cells, unlike T cells, can be directly stimulated by antigen, which then allows B cell differentiation into antibody producing plasma cells. TNF (tumor necrosis factor) and other cytokines are produced by activated T cells and augment the cellular and humoral immune response. An FDA-approved autologous dendritic cell therapy, sipuleucel-T, is currently available for the treatment of advanced prostate cancer.Dahm P, Vieweg J: Evolving immunotherapeutic strategies for the treatment of prostate and renal carcinomas. AUA UPDATE SERIES 2004, vol 23, lesson 4.Flechner SM, Finke JH, Fairchild RL: Basic principles of immunology, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 17, pp 504-505. GeneralPhysiology, Immunology, & Adrenal )

Aldosterone production is primarily:
A) a function of the zona fasciculata.
B) increased by atrial natriuretic factor.
C) decreased in renal hypoperfusion.
D) mediated by angiotensin II.
E) increased with sodium loading.

D (mediated by angiotensin II.Aldosterone levels are primarily regulated by angiotensin II through the renin-angiotensin-aldosterone system and directly by serum potassium levels. Increased sodium decreases aldosterone. Aldosterone is produced in the zona glomerulosa and not under direct control of ACTH. Renal hypoperfusion will increase aldosterone production. Kutikov A, Crispen PL, Uzzo RG: Pathophysiology, evaluation, and medical management of adrenal disorders, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 2, chap 57, pp 1697-1698. GeneralPhysiology, Immunology, & Adrenal )

A 55-year-old man with metastatic RCC to the brain is confused and has one short generalized seizure. His serum sodium is 110 mEq/l. The next step is:
A) total fluid restriction to 2 l/day.
B) I.V. normal saline at 1 ml/kg/hr.
C) I.V. hypertonic saline at 1 ml/kg/hr.
D) lithium 1200 mg daily.
E) demeclocycline 600 mg daily.

C (I.V. hypertonic saline at 1 ml/kg/hr.SIADH is caused primarily by release of ADH from brain infections, neoplasms, drugs, or surgery. The treatment of symptomatic hyponatremia from SIADH is fluid restriction and replenishment of sodium. Fluid restriction alone is not adequate in the face of a seizure. The indications for hypertonic saline should be those patients who have neurologic sequelae as noted in this scenario. Correction should raise the sodium no more than 2 mEq/l/hr or 25 mEq/l/48 hours to minimize the risk of central pontine myelinolysis. Lithium and demeclocycline are antagonists of ADH and used for more chronic conditions without concurrent neurologic symptoms. Correction of the sodium deficit is the appropriate next step.Shoskes DA, McMahon AW: Renal physiology and pathophysiology, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 2, chap 38, p 1025. GeneralPhysiology, Immunology, & Adrenal )

A 64-year-old woman undergoes left laparoscopic adrenalectomy for a non-functional 5.5 cm adrenal mass. Three pathologic criteria suggestive of the diagnosis of carcinoma include:
A) "a mitotic rate > 5/hpf, absence of clear cytoplasm, and sinusoidal invasion. "
B) "atypical mitoses, lack of necrosis, and venous invasion. "
C) "focused growth pattern, high nuclear grade, and most cells have clear cytoplasm. "
D) "capsular exclusion, sinusoidal exclusion, and atypical mitoses. "
E) "mitotic rate < 5/hpf, diffuse growth pattern, and capsular invasion.

A,(a mitotic rate > 5/hpf, absence of clear cytoplasm, and sinusoidal invasion. "Distinguishing between adrenal adenoma and carcinoma can be difficult, and large-sized adrenal lesions do not always biologically behave as carcinomas. The Weiss criteria, which includes: high mitotic rate (> 5/hpf), atypical mitoses, venous invasion, high nuclear grade (Fuhrman 3-4), absence of cells with clear cytoplasm (< 25% of cells), a diffuse growth pattern (more than one third of tumor), necrosis, sinusoidal invasion, and capsular invasion are often used to distinguish between benign and malignant potential. Three or more of these features are needed for the diagnosis of carcinoma.Kutikov A, Crispen PL, Uzzo RG: Pathophysiology, evaluation, and medical management of adrenal disorders, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 2, chap 57, pp 1715-1719. GeneralPhysiology, Immunology, & Adrenal )

A 53-year-old diabetic man sustains a minor proximal crural perforation during primary implantation of a three-piece inflatable penile prosthesis via a penoscrotal approach. The best management is:
A) abort the procedure.
B) secure exit tubing of the ipsilateral cylinder.
C) extend corporotomy for primary repair.
D) place a malleable implant.
E) direct closure via perineal approach.

B (secure exit tubing of the ipsilateral cylinder.A common intraoperative complication with penile prosthesis surgery is crural perforation. If this occurs with insertion of an inflatable device with attached tubing, placing a tunica albuginea closure suture on either side of the exit tubing to keep the cylinder in place has worked sufficiently without requiring a more extensive repair. A more significant perforation injury, including damage to the urethra, would require termination of the procedure. Placement of a malleable prosthesis is not advised as it cannot be secured and will be more likely to erode.Montague DK: Prosthetic surgery for erectile dysfunction, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 27, p 787. AdultSexual Dysfunction, Endocrinopathy, Fertility Problems )

A 43-year-old man desires a biological child with his 38-year-old wife. Both testes are 5 cm in longitudinal axis and firm on physical examination. Two semen analyses show azoospermia with volumes of 2.1 and 2.3 ml. FSH is 2.8 IU/l. The next step is:
A) adoption.
B) TRUS.
C) evaluation of the wife.
D) testicular sperm extraction with ICSI.
E) microsurgical scrotal ductal reconstruction.

C (evaluation of the wife.The likelihood of obstructive azoospermia is 96% with testis longitudinal axis greater than 4.6 cm and FSH less than 7.6 IU/l. However, the most significant predictor of any form of reproductive intervention is maternal age, with female fecundity declining precipitously after age 37. The decision to perform microsurgical scrotal ductal reconstruction or to obtain sperm from the testis for IVF and intracytoplasmic sperm injection rests on evaluation of the female partner, especially after age 37. Transrectal ultrasound is not necessary if semen volumes are normal (> 1.5 ml) as ejaculatory ductal obstruction is unlikely.Sabanegh E, Agarwal A: Male infertility, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 21, pp 619, 635. AdultSexual Dysfunction, Endocrinopathy, Fertility Problems )

A 28-year-old man with Kallmann syndrome is treated with exogenous testosterone. He desires a biological child. Semen analysis reveals a volume of 2.2 ml and azoospermia. The next step is:
A) post-ejaculate urinalysis.
B) "assay testosterone, LH, and FSH. "
C) administer GnRH.
D) administer hCG and recombinant FSH.
E) testicular sperm extraction for IVF.

D (administer hCG and recombinant FSH.Kallmann syndrome, anosmia or hyposmia associated with hypogonadotropic hypogonadism is commonly diagnosed due to a delayed onset of puberty. Most patients are treated with exogenous testosterone at the time of their diagnosis for virilization. Testosterone is easy and cost effective to administer compared to daily injections of alternative hormones. Azoospermia in these patients results from the combination of inadequate levels of intratesticular testosterone, and the patient's natural absence of stimulatory pituitary hormones. When the patient desires to father children, spermatogenesis can be brought about by discontinuing parenteral testosterone and beginning daily IM or SQ injections of hCG and recombinant FSH. If the response is insufficient, GnRH administration may be considered but is expensive and requires I.V. administration. In patients with low ejaculate volume (< 1.5 ml), a post-ejaculate urine is useful to diagnose retrograde ejaculation, this patient's ejaculate volume is normal. Assay of testosterone, LH and FSH is not needed in this patient in whom a diagnosis of Kallmann syndrome has already been made. It would be inappropriate to proceed with testicular sperm extraction without first giving the hormonal treatment necessary to stimulate spermatogenesis. Sabanegh E, Agarwal A: Male infertility, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 21, p 639. AdultSexual Dysfunction, Endocrinopathy, Fertility Problems )

A 56-year-old man has low libido and a normal physical exam. Morning serum testosterone is 365 ng/dl and prolactin is 48 ng/ml (normal < 20 ng/ml). The next step is:
A) repeat prolactin assay.
B) serum LH assay.
C) pituitary MRI scan.
D) testosterone replacement.
E) bromocriptine.

A (repeat prolactin assay.Elevated serum prolactin from a pituitary tumor that causes clinical symptoms such as low libido, infertility and gynecomastia is usually accompanied by a low serum testosterone. A mildly elevated prolactin, especially accompanying a serum testosterone in the normal range, is rarely clinically significant. Because prolactin has high interassay variability, an elevated prolactin should first be verified by repeat testing. With a normal testosterone, LH assay is unhelpful and exogenous testosterone is not indicated. Likewise, a man with mildly elevated prolactin and normal testosterone is unlikely to benefit from bromocriptine, and MRI is unlikely to reveal a clinically significant anatomic pituitary lesion. The most common cause of low libido in a man with a normal physical exam and adequate testosterone is psychological.Sabanegh E, Agarwal A: Male infertility, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 21, p 639. AdultSexual Dysfunction, Endocrinopathy, Fertility Problems )

A 32-year-old man has azoospermia. Y chromosomal microdeletion assay reveals azoospermia factor b (AZFb) and azoospermia factor c (AZFc) deletions. The next step is:
A) adoption.
B) clomiphene citrate.
C) recombinant FSH.
D) testis biopsy.
E) microsurgical testicular sperm extraction.

A (adoption.The long arm of the Y chromosome harbors genes intrinsic to spermatogenesis, including the azoospermia factor (AZF). While males with AZFc deletions may or may not have sperm in the seminiferous epithelium, an AZFa and/or AZFb deletion in combination with an AZFc deletion uniformly results in a Sertoli cell only phenotype. Biopsy is unnecessary, and microsurgical testicular sperm extraction will not yield sperm. Endocrine therapy with clomiphene citrate to stimulate Leydig cell production of testosterone, or with recombinant follicle stimulating hormone to stimulate Sertoli cell function, will not yield sperm as no germ cells are present.Jarow J, Sigman M, Kolettis PN, et al: The optimal evaluation of the infertile male. OPTIMAL EVALUATION OF THE INFERTILE MALE BEST PRACTICE STATEMENT. American Urological Association Education and Research, Inc, 2010, p 24. http://www.auanet.org/content/media/optimalevaluation2010.pdfSabanegh E, Agarwal A: Male infertility, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 21, p 641. AdultSexual Dysfunction, Endocrinopathy, Fertility Problems )

The metabolism of sildenafil may be inhibited by:
A) a fatty meal.
B) rifampin.
C) ritonavir.
D) warfarin.
E) doxazosin.

C (ritonavir.High fat meals can inhibit the absorption of sildenafil and vardenafil but do not affect the absorption of tadalafil or the metabolism of PDE5 inhibitors. Ketoconazole, itraconazole, and protease inhibitors such as ritonavir can impair the metabolic breakdown of PDE5 inhibitors by blocking the CYP3A4 pathway. These agents may increase blood levels of inhibitors, requiring a PDE5 dose reduction. Agents such as rifampin may induce CYP3A4, enhancing the breakdown of inhibitors and requiring higher PDE5 doses. Warfarin and doxazosin have no effect on the metabolism of PED5 inhibitors. Doxazosin may exacerbate hypotensive changes with PED5 inhibitors.Lue TF, Broderick GA: Evaluation of nonsurgical management of erectile dysfunction and premature ejaculation, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 22, p 750.Burnett AL: Evaluation and management of erectile dysfunction, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 24, p 742. AdultSexual Dysfunction, Endocrinopathy, Fertility Problems )

"A 32-year-old man with infertility has an ejaculate volume of 3 ml, sperm count of 13 million/ml, 50% motility, and an elevated serum FSH. Physical examination reveals bilaterally small testes, normal vasa, and no evidence of a varicocele. His 28-year-old wife has a normal evaluation. The most appropriate next step is: "
A) intrauterine insemination.
B) testicular biopsy.
C) in vitro fertilization.
D) clomiphene citrate.
E) antisperm antibody testing.

A (intrauterine insemination.The couple is infertile due to idiopathic male factor. Testicular biopsy is unlikely to be helpful in a patient with oligospermia. Any intervention used in this setting is considered empirical. The main choice is between attempts to improve the husband's fertility or assisted reproductive techniques to improve the chances of conception without altering sperm quality. It is controversial whether clomiphene citrate is occasionally effective in men with idiopathic oligospermia but it is definitely not effective in an individual with an elevated serum FSH. This leaves either intrauterine insemination (IUI) or in vitro fertilization (IVF). It is most reasonable to start with IUI in this couple since the wife is under 30 and the husband's total motile sperm count is well above 10 million. IVF would be the first therapeutic option if there were a significant female factor or his sperm count were extremely low. The patient's motility is above the reference value for motility and therefore there is no indication for antisperm antibody testing.Demir B, Dilbaz B, Cinar O, et al: Factors affecting pregnancy outcome of intrauterine insemination cycles in couples with favorable female characteristics. J OBSTET GYN 2011;31:420-423.Dorjpurev U, Kuwahara A, Yano Y, et al: Effect of semen characteristics on pregnancy rate following intrauterine insemination. J MED INVEST 2011;58:127-133. AdultSexual Dysfunction, Endocrinopathy, Fertility Problems )

"A 46-year-old-man has a sustained erection for 72 hours. His erection has persisted despite irrigation with dilute phenylephrine solution through multiple glanular punctures and a subsequent corporal-cavernosal shunt. One day later, he continues to have a rigid penis. The best treatment is: "
A) oral terbutaline.
B) oral bicalutamide.
C) corporal-glanular shunt.
D) bilateral T-shunt.
E) immediate prosthesis implantation.

E (immediate prosthesis implantation.Priapism lasting longer than 36 hours recalcitrant to multiple attempts at irrigation as well as shunting procedures, is best treated with immediate penile prosthesis implantation. While immediate implantation carries a greater risk of infection and erosion, it preserves penile length and makes prosthesis implantation easier. In this severe case of ischemic priapism, oral therapies are not indicated and he has already failed a proximal shunting procedure. A T-shunt is another form of a distal corporal-glanular shunt. A repeat proximal shunt would not be unreasonable in this individual, but would have a low chance of success and will likely be associated with significant penile shortening and fibrosis.Broderick GA: Priapism, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 25, pp 764-766. AdultSexual Dysfunction, Endocrinopathy, Fertility Problems )

A 52-year-old man with renal insufficiency has decreased libido and progressive erectile dysfunction. He has a spot serum prolactin level of 220 ng/ml (normal 5-20 ng/ml). The next step is:
A) measure serum testosterone.
B) measure FSH and LH.
C) brain CT.
D) nephrology consult.
E) ophthalmology consult.

E (ophthalmology consult.Elevated prolactin levels can cause infertility and sexual dysfunction by decreasing the production of testosterone. Mildly elevated levels (< 50ng/ml) can be seen with stress and renal insufficiency. Persistently high levels of serum prolactin are suggestive of a pituitary adenoma and need to be evaluated with a careful measurement of visual fields and an MRI of the pituitary. This patient has levels consistent with a pituitary adenoma and serum testosterone, FSH and LH will not help make the diagnosis. While he may benefit from the care of a nephrologist, it will not direct the diagnosis and treatment of a pituitary adenoma. CT is not specific enough for an evaluation of the pituitary and the best choice is an ophthalmology consult for careful visual field testing and an MRI of the pituitary.Sabanegh E, Agarwal A: Male infertility, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 21, p 639. AdultSexual Dysfunction, Endocrinopathy, Fertility Problems )

"A 68-year-old man with ESRD has been on dialysis for ten years. He has a malleable penile prosthesis and his caregivers notice a firm, black, necrotic lesion on his glans. He has similar lesions on his fingers and toes. The best treatment is: "
A) observation and support.
B) oral antibiotics for six weeks.
C) I.V. antibiotics for six weeks.
D) biopsy of lesion.
E) removal of prosthesis.

A (observation and support.This patient has metastatic calciphylaxis of the vessels (dry gangrene) in his digits and glans. This is seen in patients with ESRD and is associated with a high mortality rate. Most of these patients will die of their renal disease within six months. The characteristic lesions show microscopic calcification in the arterioles and capillaries which leads to dry necrosis. Antibiotics are not helpful and biopsies can be harmful as these lesions will not heal well due to their poor blood supply. Removal of the prosthesis would only be indicated if there was subsequent erosion or penile infection. This patient should continue with observation, support and wound care as needed.Jacobson HA: Penile calciphylaxis. UROL 2002;60,344.Frehally J: Bone and mineral metabolism in CKD: Clinical manifestations of renal osteodystrophy, in COMPREHENSIVE CLINICAL NEPHROLOGY, ed 3. Philadelphia, Mosby Elsevier, 2007, chap 74, pp 906-909. AdultSexual Dysfunction, Endocrinopathy, Fertility Problems )

"Persistent or recurrent difficulty to allow vaginal entry of a penis, finger, or other object, despite the woman's desire to participate is consistent with the diagnosis of: "
A) vaginismus.
B) persistent sexual arousal disorder.
C) dyspareunia.
D) sexual aversion disorder.
E) genital arousal disorder.

A (vaginismus.Sexual dysfunction in women is complicated in that many of the disorders coexist and isolated disorders are uncommon. Definitions frequently change or are not universally agreed upon. In the Revised Definitions for Female Sexual Dysfunction from the Second International Consensus of Sexual Medicine vaginismus is the persistent difficulty to allow entry of an object into the vagina despite the desire of the woman to participate. Dyspareunia on the other hand is persistent or recurrent pain with attempted penile-vaginal intercourse. Persistent sexual arousal disorder, sexual aversion disorder and objective arousal disorder are not primarily associated with the difficulty to insert an object into the vagina. Genital arousal disorder consists of complaints of impaired genital sexual arousal, which may include minimal vulvar swelling or vaginal lubrication from any type of sexual stimulation and reduced sexual sensations from caressing genitalia. However, subjective sexual excitement still occurs with nongenital sexual stimuli. In persistent sexual arousal disorder, the patient has spontaneous, intrusive, and unwanted genital arousal in the absence of sexual interest and desire. Arousal is unrelieved by orgasms and the feelings of arousal persist for hours or days. Extreme anxiety or disgust at the anticipation of or attempt at any sexual activity is sexual aversion disorder.Moore CK: Female sexual function and dysfunction, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 30, p 826. AdultSexual Dysfunction, Endocrinopathy, Fertility Problems )

A 52-year-old man in good health has a three year history of dorsal penile curvature. His angulation is 80 degrees and has been stable without pain for over a year. He has good erections with sildenafil but cannot penetrate due to the curvature. The best treatment is:
A) oral colchicine.
B) topical verapamil.
C) corporal plication.
D) plaque incision and graft.
E) modeling and placement of inflatable penile prosthesis.

D (plaque incision and graft.This patient has demonstrated a stable plaque in Peyronie's disease and is ready for surgical correction. Medical therapy with colchicine may be useful in the acute phase and will decrease penile pain, however it has little to no proven benefit over placebo in preventing curvature and is associated with significant GI side effects. It would not be effective in this clinical situation. Topical verapamil has not been adequately evaluated and would most likely not be effective with this degree of curvature. Plication would require multiple plicating sutures and would severely shorten the penis with this degree of curvature. Plication procedures are usually not recommended if the penile curvature is > 60 degrees due to significant shortening of the penis. As he gets excellent erections, a prosthesis is not yet indicated.Jordan GH, McCammon KA: Peyronie's disease, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 28, pp 802-808. AdultSexual Dysfunction, Endocrinopathy, Fertility Problems )

"A 35-year-old man with azoospermia and normal genetic testing desires a biological child. Testosterone is 275 ng/dl, LH is 28 IU/l and FSH is 15 IU/l. Both testes are 3 cm in length and soft. The next step is: "
A) clomiphene citrate.
B) hCG.
C) scrotal ultrasound.
D) cranial MRI scan.
E) microsurgical testicular sperm extraction.

E (microsurgical testicular sperm extraction.With FSH greater than 7.6 IU/l and testis axis less than 4.6 cm, the probability of non-obstructive azoospermia is 89%. Neither clomiphene citrate nor hCG is effective in a patient with highly elevated LH, as clomiphene acts to increase LH secretion and hCG is an LH surrogate. Scrotal ultrasound would not reveal more than that identified on physical examination. As the pituitary is responding appropriately to low serum testosterone, MRI is not indicated. The only chance of a biological child for this patient with non-obstructive azoospermia would be testicular sperm extraction for intracytoplasmic sperm injection.Sabanegh E, Agarwal A: Male infertility, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 21, p 634.Schoor RA, Elhanbly S, Niederberger CS, Ross LS: The role of testicular biopsy in the modern management of male infertility. J UROL 2002;167:197-200. AdultSexual Dysfunction, Endocrinopathy, Fertility Problems )

The indication for sperm viability testing is:
A) sperm density < 5 million sperm per ml.
B) sperm motility < 5%.
C) Kallmann syndrome.
D) Klinefelter syndrome.
E) presence of anti-sperm antibodies.

B (sperm motility < 5%.Flagellar defects result in motilities of less than 5% - 10%. In these samples most of the non-motile sperm are viable. Most cases of ultrastructural flagellar defects are associated with normal sperm densities. Kallmann syndrome is associated with hypogonadotropic hypogonadism and resultant azoospermia not motility defects. Klinefelter syndrome is associated with azoospermia, not motility defects. Antisperm antibodies may result in low motility but the non-motile sperm are non-viable.Chemes HE, Rawe VY: Sperm pathology: A step beyond descriptive morphology. Origin, characterization and fertility potential of abnormal sperm phenotypes in infertile men. HUMAN REPRODUCTION UPDATE, 2003 vol 9, pp 405-428.Sabanegh E, Agarwal A: Male infertility, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 1, chap 21, p 622. AdultSexual Dysfunction, Endocrinopathy, Fertility Problems )

A 34-year-old man amputates his penis during a psychotic episode. He is brought to the emergency department in stable condition with cold ischemia time of the amputated penis of six hours. Microvascular reconstruction or macroscopic replantation of the penile shaft provides an equivalent outcome for:
A) penile skin preservation.
B) urethral stricture formation.
C) erectile function.
D) penile sensation.
E) infection.

C (erectile function.Microvascular reconstruction involves reanastomosis of the dorsal arteries, dorsal vein, and nerves. Macroscopic replantation is the simple anastomosis of the corpora cavernosum and urethra. Erectile function after either microvascular reconstruction or macroscopic replantation of the penile shaft is roughly 50%. Penile skin loss, urethral stricture formation, and loss of penile sensation are all greater with macroscopic replantation as compared to microvascular reconstruction of the penile shaft. Infection of the penile shaft after either technique has not been studied to date.Morey AF, Dugi DD III: Genital and lower urinary tract trauma, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 3, chap 88, p 2509. Adult,Trauma & Fistulae)

A 40-year-old man with spina bifida undergoes ileovesicostomy and bladder neck closure with omental flap interposition for severe incontinence. Three months later he develops recurrent incontinence from a vesicourethral fistula. The next step is:
A) tube vesicostomy.
B) permanent nephrostomy tubes.
C) repeat bladder neck closure with omental interposition.
D) repeat bladder neck closure with rectus flap interposition.
E) ileal conduit.

D (repeat bladder neck closure with rectus flap interposition.Persistent vesicourethral fistula occurs frequently with bladder neck closure where vascularized tissue is not interposed between the bladder neck and urethra. Omentum is the most commonly used tissue for interposition but occasionally is not available or cannot be brought down to the level of the bladder neck closure. When this is not possible, or in high risk cases (radiated patients, persistent vesicourethral fistulae, etc.) a rectus abdominus pedicle flap can be used for interposition. Tube vesicostomy will not help this patient as he will continue to be incontinent and it has been a lengthy interval since his surgery. Permanent nephrostomy tubes are undesirable and the patient may well continue to be incontinent. An ileal conduit can be considered but would be significantly more extensive than repeating the bladder neck closure.Rovner ES: Urinary tract fistulae, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 3, chap 77, p 2238. Adult,Trauma & Fistulae)

"A 78-year-old malnourished woman with a history of prior pelvic radiation for cervical cancer undergoes a radical cystectomy and ileal loop diversion with bilateral ureteral stents for urothelial cancer. At the time of surgery, the bowel shows signs of radiation changes. Four days post-operatively, her urine output decreases with a marked increase in output from her abdominal drain. The next step is: "
A) parenteral hyperalimentation.
B) placement of a catheter into the ileal stoma.
C) bilateral percutaneous nephrostomy tube placement.
D) revision of the ureteroileal anastomoses.
E) excision of the ileal loop and replacement with a transverse colon conduit.

B (placement of a catheter into the ileal stoma.Leakage and fistula from urinary diversion occur in 2 to 9% of patients. However, 20 to 60% of these fistulae close spontaneously. Conservative management can be safely attempted assuming the patient is not septic and that adequate drainage is maintained. Leakage could be from the ureteral ileal anastomosis or from the butt end of the conduit. Bilateral ureteral stents are already in place, which should address any concerns about a ureteral ileal anastomotic leak. Therefore, the best initial therapeutic maneuver in this patient is placement of a catheter into the ileal loop to facilitate drainage. While hyperalimentation is important in malnourished patients and should also be initiated, this would not address the immediate issue of the leak. If the stomal catheter failed to decrease the fistulous output, bilateral percutaneous nephrostomy tubes could be placed to divert the urinary stream. If this failed, surgical intervention would be required to address the problem.Skinner EC, Skinner DG, Stein JP: Orthotopic urinary diversion, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 3, chap 87, p 2502. Adult,Trauma & Fistulae)

A 38-year-old woman develops monthly cyclical episodes of hematuria and menouria one year following Caesarean section. She does not desire more children. CT urogram demonstrates contrast in the bladder and uterine cavity; there is no hydronephrosis. The best treatment is:
A) "cystoscopy, fulguration and catheter drainage. "
B) LH-RH agonist.
C) transvaginal repair with Martius flap.
D) transvaginal repair with omental flap.
E) transabdominal repair with hysterectomy.

E (transabdominal repair with hysterectomy.Vesicouterine fistula (also known as, Youssef syndrome) is found to be the etiology for 2-4% of all genitourinary fistula. A vesicouterine fistula is a rare complication that classically develops following a Cesarean section. The mechanism of the injury occurs as a consequence of incorporating the bladder wall with the sutures used to close the Cesarean section site, hence, it is frequently a delayed complication noted only as the sutures dissolve. It is also occasionally seen to arise following a dilation and curettage (D and C) procedure or as a consequence of a vaginal delivery following a prior Cesarean section.Due to the sphincteric like activity of the uterine cervix, these patients may not present with urinary incontinence. Indeed, 60% of the patients will present with intermittent or cyclical gross hematuria (menouria; menstrual tissue passed through the urine when voiding) as their only symptom, 20% with chronic urinary incontinence (incompetent uterine sphincter), and 20% with the classic Youssef triad: menouria, amenorrhea (all menstrual tissue passed into the urine) and chronic urinary incontinence.Since radiographic and endoscopic studies may frequently be inconclusive, the diagnoses of this complication requires a high degree of clinical suspicion. Tests used will consist of cystoscopy in an attempt to visualize the fistula tract, ultrasonography, CT cystogram, MRI scan, or hysterosalpingogram, the latter of which is presumably the most certain diagnostic technique available. Once the diagnosis is made, additional tests to rule-out concurrent ureteral injuries must be performed.If the diagnosis of a vesicouterine fistula is made within three to six months of the surgery, conservative treatment with a indwelling urethral catheter and endocrine suppression of menstrual flow has been successful in > 50% of patients. Once the tract has matured and epithelized as in this case, treatment is based on the future fertility desires of the patient. If the individual does not desire to have further children, the most definitive treatment is by transabdominal hysterectomy and repair of the bladder. If additional child bearing is requested, either transvaginal, or transabdominal approaches may be used dependent upon the location of fistula. Juxtaposition of adjacent tissue such as omentum or a labial fat pad (Martius flap) greatly reduces the likelihood of recurrence. These dissections are frequently complicated and placement of bilateral ureteral stents prior to the surgery to help identify the ureters is recommended. Rovner ES: Urinary tract fistulae, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 3, chap 77, pp 2246-2268. Adult,Trauma & Fistulae)

"A 37-year-old woman with a suspected urinary fistula undergoes an in-office double dye test. There is orange staining of the upper gauze pad. The middle gauze pad is dry, and the lower gauze pad is slightly stained blue. The most likely diagnosis is: "
A) ureterovaginal fistula.
B) vesicovaginal fistula.
C) ureterovaginal and vesicovaginal fistula.
D) ureterovaginal fistula and urethral leakage.
E) vesicovaginal fistula and urethral leakage.

D (ureterovaginal fistula and urethral leakage.The in-office dye test begins with prescribing oral phenazopyridine several days prior to office visit. As expected, this process will turn the urine orange. At time of office visit, the bladder is filled with dilute methylene blue via urethral catheter infusion. Thus, bladder fluid will have blue coloration, and ureteral urine is expected to have orange discoloration. Three gauze pads are placed in the vagina, the upper pad is near the cuff, and the middle pad is within the vagina, usually above the bladder neck. The lower pad is usually below the bladder neck and urethra. In this pattern of staining, orange urine in the upper pad is concerning for the presence of a ureteral source of drainage into the vagina, most commonly a ureterovaginal fistula. The appearance of blue staining on the lower pad is most consistent with urethral leakage. Thus this patient has results suggestive of a ureterovaginal fistula and urethral leakage. The presence of blue on the upper or middle pad without leakage on the lower pad would suggest a vesicovaginal fistula.Rovner ES: Urinary tract fistulae, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 3, chap 77, p 2243. Adult,Trauma & Fistulae)

A 22-year-old man sustains a severe burn of his genitalia. There is marked bullous edema and eschar formation of the entire penis and much of the scrotum. He has had a catheter in his urethra for three days to monitor urine output. The next step is:
A) radical eschar debridement.
B) split thickness skin grafts.
C) hyperbaric oxygen therapy.
D) remove urethral catheter and insert suprapubic tube.
E) observe for wound granulation.

D (remove urethral catheter and insert suprapubic tube.Multiple debridements of necrotic skin followed by skin graft coverage may eventually be needed with burn injuries to the genitalia. Early suprapubic urinary diversion simplifies wound care and prevents complications related to prolonged urethral catheterization. If a urethral catheter is used in a genitalia burn, it should be removed after 72 hours to prevent urethral slough and fistula formation. Hyperbaric oxygen therapy has been used to promote overall wound healing however there is no evidence that it prevents urethral complications. Split or full thickness skin grafting is used once granulation tissue is present and all non-viable tissue has been removed. Morey AF, Dugi DD III: Genital and lower urinary tract trauma, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 3, chap 88, p 2512. Adult,Trauma & Fistulae)

A 16 cm intussuscepted ureteral segment is noted in the bladder after a difficult ureteroscopic stone extraction. The next step is:
A) nephrectomy.
B) transuretero-ureterostomy.
C) ureteral reimplantation.
D) percutaneous nephrostomy drainage.
E) primary uretero-ureterostomy.

D (percutaneous nephrostomy drainage.An intussuscepted ureteral segment noted after ureteroscopic stone extraction is a dramatic complication. Retrograde realignment for such a large segment is unrealistic. Percutaneous nephrostomy drainage preserves renal function and minimizes urinary extravasation. Nephrectomy or ileal ureteral replacement may be appropriate actions only after a discussion with the patient and their family. Transuretero-ureterostomy reconstruction places both kidneys at risk especially with a history of urinary stone disease.Matlaga BR, Lingeman JE: Surgical management of upper urinary tract calculi, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 2, chap 48, p 1407. Adult,Trauma & Fistulae)

"A 42-year-old man sustains a high velocity pelvic gunshot wound with no obvious ureteral injury at exploration. Two days later during a second look operation for bleeding, a minor distal ureteral contusion is identified. Intravenous indigo carmine does not reveal a urine leak. The next step is: "
A) observation.
B) cystoscopy and stent placement.
C) percutaneous nephrostomy.
D) ureteroneocystostomy.
E) debridement and ureteroureterostomy.

B (cystoscopy and stent placement.The patient has a ureteral contusion to the distal ureter following a gunshot wound. There is no evidence of devitalized tissue or a urine leak. Cystoscopy and ureteral stent placement is the best option for a minor contusion. Ureteral reimplant is the best treatment option if a large contusion or devitalized tissue is identified. Ureteroureterostomy of the distal ureter is never indicated. Percutaneous nephrostomy would divert the urine yet would not stent the ureter which may lead to stricture formation. Observation is not indicated as the ureter may become obstructed from the contusion.Santucci RA, Doumanian LR: Upper urinary tract trauma, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 2, chap 42, p 1184. Adult,Trauma & Fistulae)

"A 25-year-old man undergoes excision and primary anastomosis for a 2 cm bulbar urethral stricture. Postoperatively the patient experiences normal erectile function, but difficulty with antegrade ejaculation. The structure most likely injured is the: "
A) bulbospongiosus.
B) transverse perineum.
C) bulbocavernosus muscle.
D) corpus cavernosum.
E) corpus spongiosum.

C (bulbocavernosus muscle.The bulbocavernosus muscle is most responsible for antegrade ejaculation through rhythmic contractions that compress the bulb to expel semen from the urethra. Significant injury or damage to this structure is thought to cause ejaculatory dysfunction. The corpus spongiosum pressurizes and constricts the urethra during ejaculation. The bulbospongiosus, and transverse perineum do not contribute to ejaculation. Injury to the corpus cavernosum could result in erectile dysfunction.Lue TF: Physiology of penile erection and pathophysiology of erectile dysfunction, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 6, chap 23, p 690. Adult,Trauma & Fistulae)

"A nine-year-old girl is struck in the abdomen and right flank by an automobile. She is alert and her vital signs are stable. She has moderate guarding in her right upper quadrant and decreased bowel sounds. Her hematocrit is 33%, and she has blood-tinged urine. A CT scan demonstrates a 4 cm hepatic laceration and hematoma and a 3 cm laceration of the right kidney with minimal contrast extravasation. The next step is: "
A) observation.
B) cystoscopy and ureteral stent placement.
C) renal and hepatic arteriography.
D) percutaneous drain placement.
E) abdominal exploration.

A (observation.In children who sustain blunt abdominal trauma, CT scan can define injuries to the abdominal viscera quite well. Conservative treatment in the hemodynamically stable patient with follow-up CT scan, if needed, will result in reducing the rate of abdominal exploration in the patient with stable visceral injuries to less than 10%. Cystoscopy and ureteral stent placement in this patient with a grade 3 renal laceration is not indicated, unless clinical symptoms, such as a prolonged ileus or sepsis should develop. Renal and hepatic arteriography would be indicated if there is decreasing hematocrit with increasing size of hematoma, and may allow for selective embolization of the bleeding vessel(s), potentially eliminating the need for exploration. Surgical exploration with repair of lacerations is not indicated in this stable patient and in some cases may result in disruption of hematoma, bleeding and unnecessary nephrectomy.Husmann DA: Pediatric genitourinary trauma, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 4, chap 138, p 3739. Pediatric,Trauma & Fistulae)

"A four-year-old boy fell from a second story window. On examination, his vital signs are stable, but he has right flank and upper quadrant abdominal tenderness and fullness. He does not have peritoneal signs. Urinalysis is normal. The next step is: "
A) observation.
B) abdominal paracentesis.
C) abdominal and renal ultrasound.
D) cystogram.
E) CT urogram.

E (CT urogram.This boy has suffered a rapid deceleration injury and this mechanism of injury warrants evaluation with imaging. A pedicle injury or complete avulsion of the UPJ are potential injuries. These can both occur without hematuria. Hence, observation would be inappropriate. An abdominal tap for blood would not diagnose a renal injury. An ultrasound would likely not be diagnostic. A cystogram in a trauma patient is only indicated in the presence of gross hematuria or pelvic fracture. CT scan is diagnostic and more likely to identify other potential abdominal injuries.Husmann DA: Pediatric genitourinary trauma, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 4, chap 138, p 3732. Pediatric,Trauma & Fistulae)

"A one-day-old girl with spina bifida undergoes back closure and one week later has placement of a ventriculoperitoneal shunt. Following catheter removal, she voids with a moderate residual. Cred? maneuver is started. Eight hours later, she develops abdominal distension and has minimal urine output. The bladder is catheterized for 3 cc. The next step is: "
A) fluid bolus.
B) plain film of the abdomen.
C) cystogram.
D) abdominal/pelvic CT scan.
E) laparotomy.

C (cystogram.Forceful expression of the over-distended bladder in the neonate, cystoscopy, inguinal hernia repair, and umbilical vessel catheterization are the most common causes of iatrogenic injuries to a child's bladder and may on rare occasions in association with VUR result in forniceal rupture. Although the Cred? maneuver is used less commonly, it can be employed in infants who do not empty their bladders completely. However, the Cred? voiding is contraindicated in children with a reactive external sphincter and should not be initiated in children with spinal bifida until they have been assessed with urodynamics. The Cred? maneuver stimulates a reflux response in the external sphincter that increases urethral resistance, thereby increasing the pressure needed to expel urine from the bladder. Bladder rupture has occurred and VCUG will be diagnostic in most cases. Fluid bolus is unnecessary because there is no reason to suspect volume depletion and may delay diagnosis. Although plain film of the abdomen and CT scan without delay imaging may be suggestive of ascites, they are not diagnostic. CT cystogram is acceptable but results in excessive radiation exposure. Laparotomy is not indicated until a diagnosis is made.MacLellan DL, Bauer SB: Neuropathic dysfunction of the lower urinary tract, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 4, chap 128, p 3439. Pediatric,Trauma & Fistulae)

A healthy 66-year-old woman has a loopogram as shown seven years following cystectomy and ileal conduit for bladder cancer. CT scan demonstrates bilateral hydronephrosis and no evidence of recurrent disease. Chest x-ray and urine cytology are normal. Serum creatinine is 1.8 mg/dl. A renogram is also shown. The next step is:
A) looposcopy.
B) bilateral percutaneous nephrostomy.
C) stomal revision.
D) revision of left ureteroileal anastomosis.
E) left nephroureterectomy.

E (left nephroureterectomy.This patient has developed upper tract deterioration following cystectomy and ileal conduit diversion. This has been reported in some series to occur in over 50% of patients with long-term followup. The renogram in this instance demonstrates no obstruction to the right renal unit with hydronephrosis likely the result of chronic reflux. The renogram also demonstrates no significant function of the left renal unit. Because there is no reflux into the left system it cannot be monitored as to the possible development of upper tract urothelial carcinoma. In this setting, nephroureterectomy is recommended. Looposcopy will not add to the evaluation as it will not provide access to the left system. Bilateral percutaneous nephrostomy is not indicated because there is no evidence of obstruction of the right side. Similarly, there is no evidence of stomal stenosis. Revision of left ureteroileal anastomosis should not be undertaken for a non-functioning kidney. Another option would be left nephrostomy tube placement, antegrade studies, and selective cytology to further risk stratify the patient prior to making a final decision. Dahl DM, McDougal WS: Use of intestinal segments in urinary diversion, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 3, chap 85, p 2411. Adult,Urinary Diversion)

"A 37-year-old woman with a continent cutaneous urinary diversion becomes febrile and develops mental status changes and marked hepatic dysfunction. Previously, her hepatic function had been normal. In addition to prompt urinary drainage and systemic antibiotics, the next step is: "
A) lactulose.
B) Vitamin B12.
C) sodium bicarbonate.
D) nicotinic acid.
E) thiamine and folic acid.

A (lactulose.Urinary ammonium excreted by the kidneys is reabsorbed by the intestinal segment, and then returned to the liver via the portal circulation. The liver metabolizes ammonium to urea via the ornithine cycle. The liver usually adapts to the excess ammonia in the portal circulation without difficulty and rapidly metabolizes it. In the setting of hepatic dysfunction, the hepatic reserve for ammonium metabolism may be exceeded, resulting in the complication of an ammoniagenic coma. The syndrome, however, also has been described in patients with normal hepatic function. Systemic bacteremia, with endotoxin production, inhibits hepatic function and may precipitate this clinical entity. Urinary tract infections with urea-splitting organisms may also overload the ability of the liver to clear the ammonia. If this syndrome occurs in a patient suspected of having near normal hepatic function, systemic bacteremia or urinary obstruction should be suspected. Prompt urinary drainage with treatment of the offending urinary pathogens along with systemic antibiotics and the administration of oral neomycin or lactulose to reduce absorption of ammonia in the gastrointestinal tract are the key components to patient management. There is no indication for the use of Vitamin B12, sodium bicarbonate, nicotinic acid, thiamine and folic acid in this clinical setting. Demarco RT, Koch MO: Metabolic complications of continent urinary diversion. AUA UPDATE SERIES 2003, vol 22, lesson 15, pp 114-119. Adult,Urinary Diversion)

The primary goal of bowel detubularization at the time of neobladder construction is to:
A) recreate the shape of the native bladder.
B) provide more efficient neobladder emptying.
C) reduce lumen pressure.
D) reduce vesicoureteral reflux.
E) reduce urinary contact time.

C (reduce lumen pressure.Early studies of orthotopic reconstruction by Camey and others demonstrated that while continence can be achieved utilizing a tubularized segment of bowel as a urinary reservoir, upper tract deterioration inevitably occurred due to high reservoir pressure. In part, the pressure in such segments is due to the continued organized bowel peristalsis, and the reduced diameter of the lumen. The observation that reservoir pressure is lowered by increasing the internal radius of the reservoir is based upon Lapace's law that mural tension is equivalent to pressure times radius cubed. While the increased radius achieved by detubularization and folding of the bowel also results in increased reservoir capacity, the primary goal of detubularization is reduction in pressure through reduction of organized peristalsis and wall tension. Although this may indirectly lead to reduced ureteral reflux, it is not the primary reason for bowel detubularization.Skinner EC, Skinner DG, Stein JP: Orthotopic urinary diversion, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 3, chap 87, p 2479. Adult,Urinary Diversion)

A 56-year-old woman three years after a radical cystectomy and continent cutaneous diversion has abdominal pain over the pouch and explosive leakage of urine despite regular catheterization. The next step is:
A) placement of indwelling urinary catheter.
B) pouchoscopy.
C) urine culture and empiric antibiotic therapy.
D) CT pouch-o-gram.
E) surgical revision of the catheterizable stoma.

C (urine culture and empiric antibiotic therapy.The clinical presentation of abdominal pain in the area of a continent cutaneous diversion and explosive urinary leakage from the stoma (as opposed to dribbling leakage) is consistent with pouchitis. While asymptomatic bacteruria is common in patients who have undergone continent cutaneous diversion and does not usually require any treatment, symptomatic pouchitis should be treated. The explosive nature of the incontinence is related to hypercontractility of the bowel in the face of infection. Short courses of antibiotics (less than ten days) are not usually successful to clear the infection, presumably due the larger amounts of mucus and sediment seen in intestinal pouches. CT cystogram of the pouch would be useful if rupture of the pouch was suspected. However, clinical symptoms in this setting are not consistent with that diagnosis. Placement of an indwelling urinary catheter, while not harmful in this setting, would have no effect on the pouch infection. Surgical revision of the stoma is unwarranted when incontinence is likely due to infection.McKiernan JM, DeCastro GJ, Benson MC: Cutaneous continent urinary diversion, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 3, chap 86, p 2450. Adult,Urinary Diversion)

"A 51-year-old woman develops bilateral hydronephrosis from benign uretero-enteric strictures, two years after undergoing a radical cystectomy with ileal conduit urinary diversion. The most successful treatment is: "
A) antegrade bilateral endoscopic balloon dilatation.
B) antegrade bilateral endoscopic laser incision.
C) retrograde bilateral balloon dilatation.
D) retrograde bilateral endoscopic laser incision.
E) open bilateral surgical revision.

E (open bilateral surgical revision.Although short-term success rates (within the first year post treatment) are high with endoscopic treatments, ranging from >60% to 100%, the long term success rates are quite low regardless of approach or endoscopic treatment. The most definitive treatment is open surgical repair.Tal R, Sivan B, Kedar D, et al: Management of benign ureteral strictures following radical cystectomy and urinary diversion for bladder cancer. J UROL 2007;178:538-542.Msezane L, Reynolds WS, Mhapsekar R, et al: Open surgical repair of ureteral strictures and fistulas following radical cystectomy and urinary diversion. J UROL 2008;179:1428-1431. Adult,Urinary Diversion)

"A 55-year-old woman underwent cystectomy and urinary diversion three years ago. Her serum electrolytes are: Na 140 mEq/l, K 3.4 mEq/l, Cl 140 mEq/l, CO2 15 mEq/l. Her urinary diversion is most likely a(n): "
A) ileal conduit.
B) jejunal conduit.
C) ileocolic pouch.
D) cutaneous ureterostomy.
E) ureterosigmoidostomy.

C (ileocolic pouch.Metabolic complications may result from interposition of intestine in the urinary tract. These generally result from altered urinary solute reabsorption by the intestine. This patient has a hyperchloremic metabolic acidosis with associated mild hypokalemia. This is typical of diversion options that utilize ileum and colon. The mechanism is due to the ionized transport of ammonium. The exchange of the weak acid, NH4, for a proton is coupled with the exchange of bicarbonate for chloride. Ammonium chloride is absorbed across the intestinal lumen into the blood in exchange for carbonic acid (i.e., CO2 and water). This is most likely to occur when urine is in prolonged contact with the bowel or if a long bowel segment is used. Electrolyte disorders resulting from jejunal interposition (particularly, proximal segments) in the urinary tract include hyponatremia, hypochloremia, hyperkalemia, azotemia, and acidosis. When stomach is used, a hypochloremic, hypokalemic metabolic alkalosis may ensue. Patients undergoing ureterosigmoidostomy may also experience metabolic acidosis, but this is generally associated with a profound hypokalemia. Dahl DM, McDougal WS: Use of intestinal segments in urinary diversion, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 3, chap 85, p 2411. Adult,Urinary Diversion)

"The need for operative revision of stomal stenosis in a continent, catheterizeable channel is reduced by: "
A) increasing size of catheter.
B) increasing frequency of catheterization.
C) steroid injection of stoma.
D) use of a pre-lubricated catheter.
E) leaving a catheter through superficial portion of stoma nightly.

E (leaving a catheter through superficial portion of stoma nightly.The usual first line approach for the problem of cutaneous stenosis of a Monti or Mitrofanoff channel is to leave a catheter through the stoma for some period of time. The concern with leaving a full-time indwelling catheter to stent"" the stoma for several days is that it may plug with mucous and introduce bacteria along its surface into the bladder. Mickelson et. al. reported use of the ""L-stent"" a catheter with a knot tied just 1-2 inches from the tip inserting it up to the knot at night with taping to hold it in place. This serves to stent only the cutaneous stoma and not enter the bladder itself. Their success with a modest period of nighttime stenting was excellent. None of the other approaches listed have shown particular impact on this problem.Mickelson JJ Yerkes EB Meyer T et al: L stent for stomal stenosis in catheterizable channels. J UROL 2009;182:1786-1791."" Pediatric,Urinary Diversion)

"A ten-day-old boy with a transverse colostomy performed for a high imperforate anus has a serum Cl of 115 mEq/l, Na of 145 mEq/l, K of 4.5 mEq/l, and CO2 of 17 mEq/l. The most likely explanation for these findings is: "
A) sepsis.
B) renal dysplasia.
C) severe hydronephrosis.
D) neurogenic bladder dysfunction.
E) electrolyte absorption from large bowel.

E (electrolyte absorption from large bowel.Genitourinary anomalies associated with an imperforate anus are common. The most common GU anomalies are; vesicoureteral reflux found in 40%, renal agenesis 25%, renal ectopy in 25%, rectourethral or rectal vaginal fistula in 20-30%, neurogenic bladder in 15- 25%, and a tethered spinal cord in 2-8%. The latter three, rectourethral fistula, neurogenic bladder, and tethered spinal cord are more frequently found in patients with a high or supra levator imperforate anus. When a rectourethral fistula exists, urine can flow into the colon leading to electrolyte resorption and recurrent UTIs even following placement of a diverting colostomy. If the electrolyte dysfunction is severe, consideration for a vesicostomy may be necessary to correct the acidosis. Intermittent catheterization in children with an active urethral rectal fistula is problematic, with the fistula acting as a false channel.Adams MC, Joseph DB: Urinary tract reconstruction in children, Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 10. Philadelphia, Elsevier Saunders, 2012, vol 4, chap 129, p 3479-3487. Pediatric,Urinary Diversion)

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