Genitourinary Emergencies

Review Test


1. A 27-year-old woman presents with a complaint of feeling week and light-
headed. On physical examination you note a pale young woman with a pulse
of 110 while supine and 90 when standing, and a blood pressure of 100/70
while supine and 70/50 while standing. Initial laboratory values report a blood
urea nitrogen (BUN) of 32 and a creatinine of 1.5. which of the following
findings points to a pre-renal etiology of her acute renal failure (ARF)?

(A) Fractional excretion of sodium = 0.8
(B) Urine osmolarity = 278
(C) Urine sodium = 47
(D) Blood urea nitrogen = 32
(E) All of the above are consistent with a pre-renal ARF.

2. Which of the following is a plausible etiology for this patients prerenal ARF?

(A) Kidney stones
(B) Systemic lupus erythematosus
(C) Ingestion of radiographic contrast dye
(D) Recent vomiting and diarrhea
(E) All of the above are plausible etiologies for prerenal ARF.

3. A 56-year-old man presents with the following laboratory data: blood urea
nitrogen (BUN) = 45, serum sodium = 135, serum creatinine = 4.1, serum
osmolarity = 280, urinary sodium (UNa) = 50, urine creatinine = 56. Which of
the following is the correct value for this patients fractional excretion of
sodium (FE Na) ?

(A) FE Na = .027
(B) FE Na = 2.7
(C) FE Na = 27
(D) FE Na = 250
(E) The FE Na cannot be calculated from the information given.

4. Which of the following types of renal failure does the patient described in
question 3 likely have?
(A) Pre-renal
(B) Renal
(C) Post-renal
(D) Acute
(E) Chronic
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5. A 44-year-old man with acute renal failure has a serum potassium level of 6.0
mEq/L. He is currently asymptomatic, but his electrocardiogram (ECG)
demonstrates peaked T waves as well as some nonspecific changes. Which of
the following would be your preferred treatment choice?

(A) 5 g Kayexalate (resin) in 25 ml of 70% sorbitol.
(B) Intravenous saline via two-large-bore peripheral lines at 150 ml/hr
(C) 10 ml of 10% calcium gluconate
(D) Ipratropium bromide via nebulizer
(E) There is no need to treat a potassium level of 6.0 mEq/L.

6. A 27-year-old male athlete presents with new-onset painless hematuria.
Dipstick analysis of the urine shows blood, but microscopic analysis reveals
no red blood cells. Which of the following possibilities would explain these
findings?

(A) Factitious disorder
(B) Recent consumption of rhubarb pie
(C) Recent ingestion of phenazopyridine
(D) Myoglobinuria
(E) All of the above are plausible explanations

7. A 34-year-old man, currently under psychiatric treatment for depression,
presents to the emergency department with a painful erection that has been
present for the past 2 hours. He also reports dysuria and a feeling that he is
unable to urinate. What is the most likely diagnosis?

(A) Phimosis
(B) Priapism
(C) Balanoposthitis
(D) Paraphimosis
(E) Penile fracture

8. A 37-year-old male diabetic patient presented to the emergency department
with excruciating pain in the scrotum that extends into the rectal area.
Findings on physical examination are unremarkable except for exquisite
tenderness. The penis is without ulceration, and the foreskin has been removed
by circumcision. Rectal examination reveals good sphincter tone, a slightly
enlarged prostate, and guaiac-negative stool. Despite the paucity of findings,
which of the following diagnosis must be considered?

(A) Priapism
(B) Phimosis
(C) Anal fissure
(D) Fourniers gangrene
(E) Chronic prostatitis




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9. Which of the following findings confirms a diagnosis of urinary retention?

(A) Post-voiding residual volume > 250 ml
(B) A distended bladder
(C) Suprapubic tenderness
(D) Pyuria of catheterized urine
(E) Presence of red blood cell casts in urine




Answers and Explanations


1-A. Pre-renal acute renal failure (ARF) is characterized by fractional excretion of
sodium (FE Na) < 1.0, a blood urea nitrogen/creatinine (BUN/Cr) ratio 20:1 ( this
patients ratio is 21.3:1), a urine osmolarity > 500, and a urine sodium of < 20. Of the
choices listed, only choice A, fractional excretion of sodium = 0.8, is consistent with
pre-renal failure. For laboratory values of different types of acute renal failure, see
table 5-1.

2-D. Of the choices listed, only hypovolemia secondary to vomiting and diarrhea is a
prerenal etiology of acute renal failure (ARF). Kidney stones are a postrenal
(obstructive) cause of ARF. Systemic lupus erythematosus (SLE) and ingestion of
radiographic contrast dye are renal etiologies of ARF. See table 5-1 for further
details.

3-B. The fractional excretion of sodium (FE Na) is calculated as follows:

U Na X serum creatinine X 100 50 (4.1) (100)
FE Na = = = 2.7
Serum Na+ X urine creatinine 135 (56)

4-B. This patient has a blood urea nitrogen/creatinine (BUN/Cr) ratio of 11, a
fractional excretion of sodium (FE Na) of 2.7 (>1), and a urinary sodium (U Na) = 50( >
40). This places him in ARF of renal etiology ( see table 5-1). It is not possible given
the information provided to determine whether this patients renal failure is acute or
chronic.

5-C. Although a potassium level of 6.0 mEq/L alone in an asymptomatic patient may
not be sufficient reason to treat for hyperkalemia, the presence of electrocardiogram
(ECG) changes does warrant treatment. The treatment of choice among those listed is
calcium gluconate, because its onset of action is just a few minutes. Kayexalate resin
also is an effective way to treat heperkalemia, but it has a slower onset of action, at
approximately 30 minutes. It is an incorrect answer to this question, however, because
the dose specified, 5 g, is incorrect. The correct dose is 25g in 25 ml of 70% sorbitol.
Intravenous saline does nothing to displace potassium and therefore would not be a
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correct treatment for this patient. Albuterol, a common drug used in asthma, is also
another treatment for hyperkalemia, but Ipratropium bromide is not.

6-E. All of the choices are possible explanations. Painless hematuria can be the result
of a factitious disorder, recent consumption of rhubarb pie, recent ingestion of
phenazopyridine, or myoglobinuria, among other causes.

7-B. This patient most likely has priapism secondary to medications. Trazodone, a
selective serotonin reuptake inhibitor (SSRI) commonly used to treat depression, is
particularly notorious for having this adverse effect.

8-D. Pain out of proportion to physical examination findings is the hallmark of
Fourniers gangrene. Priapism is painful prolonged erection. Phimosis is tightness of
the foreskin of the penis, a diagnosis that is irrelevant in a circumcised patient. Anal
fissure would produce pain on defecation and, often, a guaiac-positive stool secondary
to fresh blood; in addition, it would not cause pain in the scrotum. Chronic prostatitis
would not produce this degree of pain; in fact, chronic prostatitis often is
asymptomatic.

9-A. Urinary retention is defined s a post-voiding residual volume of > 250 ml. A
distended bladder and suprapubic tenderness are signs of urinary retention, but these
findings alone do not make the diagnosis. Pyuria of catheterized urine simply suggests
infection. The presence of red blood cell casts in the urine suggests hematuria of an
upper tract etiology.
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