Urology

1- 80-year-old man presented with dull aching pain in the loins. Investigations showed high
urea and creatinine. Ultrasound of the abdomen showed bilateral hydronephrosis. Most
common cause is:
A. Stricture of urethral meatus
B. Neoplasm of the bladder
C. Prostatic enlargement
D. Pelvic CA
E. Retroperitoneal fibrosis
Hydronephrosis and hydroureter can range from benign processes, such as the physiologic hydroureteronephrosis of
pregnancy, to potential life-threatening situations, such as infected hydronephrosis or pyonephrosis. Although
patients usually present with some signs or symptoms, hydronephrosis can be an incidental finding encountered
during the evaluation of an unrelated process. If unrecognized or left untreated, hydronephrosis and hydroureter
secondary to obstruction can lead to hypertension, loss of renal function, and sepsis. Consequently, all patients
found to have hydronephrosis or hydroureter should undergo a thorough evaluation and should be referred to a
urologist.
Sex
In women, gynecologic cancers and pregnancy are common causes. As such, among younger patients (aged 20-60
y), the frequency of hydronephrosis is higher in women than in men.
In men, obstruction secondary to prostatic hypertrophy and prostate cancer are the major causes of
hydronephrosis. Consequently, among older patients (>60 y), the frequency of hydronephrosis is higher in men than
in women.

Age
In young adults, calculi are the most common causes of hydroureter and hydronephrosis.
In children, reflux and ureteropelvic junction obstruction are common causes.

Clinical
History
Symptoms vary depending on whether the hydronephrosis is acute or chronic.
With acute obstruction, patients may present with pain, which is usually described as severe, intermittent, and
dull. Patients may describe worsening of pain with consumption of fluids. Depending on the level of hydroureter,
pain may radiate to the ipsilateral testicle or labia. Often associated with nausea and vomiting, pain from an
obstructed system is referred to as renal colic.
A history of hematuria may herald a stone or malignancy anywhere in the urinary tract.
A history of fever or diabetes adds urgency to the evaluation and treatment.
A history of a solitary kidney is an emergent situation.
Hydronephrosis may develop silently, without symptoms, as the result of advanced pelvic malignancy or severe
urinary retention from bladder outlet obstruction.
Bilateral symmetrical hydronephrosis usually suggests a cause related to the bladder, such as retention, prostatic
blockage, or severe bladder prolapse.1
Physical
With severe hydronephrosis, the kidney may be palpable.
With bilateral hydronephrosis, lower extremity edema may occur. Costovertebral angle tenderness on the affected
side is common.
A palpably distended bladder adds evidence of lower urinary tract obstruction.
A digital rectal examination should be performed to assess sphincter tone and to look for hypertrophy, nodules, or
induration of the prostate.
Causes
A multitude of causes exist for hydronephrosis and hydroureter. Classification can be made according to the level
within the urinary tract and whether the etiology is intrinsic, extrinsic, or functional.
Ureter
o Intrinsic
Ureteropelvic junction stricture
Ureterovesical junction obstruction
Papillary necrosis
Ureteral folds
Ureteral valves
Ureteral stricture (iatrogenic)
Blood clot
Benign fibroepithelial polyps
Ureteral tumor
Fungus ball
Ureteral calculus
Ureterocele
Endometriosis
Tuberculosis
Retrocaval ureter
o Functional
Gram-negative infection
Neurogenic bladder
o Extrinsic
Retroperitoneal lymphoma
Retroperitoneal sarcoma
Cervical cancer
Prostate cancer
Retroperitoneal fibrosis
Aortic aneurysm
Inflammatory bowel disease
Ovarian vein syndrome
Retrocaval ureter
Uterine prolapse
Pregnancy
Iatrogenic ureteral ligation
Ovarian cysts
Diverticulitis
Tuboovarian abscess
Retroperitoneal hemorrhage
Lymphocele
Bladder
o Intrinsic
Bladder carcinoma
Bladder calculi
Bladder neck contracture
Cystocele
Primary bladder neck hypertrophy
Bladder diverticula
o Functional
Neurogenic bladder
Vesicoureteral reflux
o Extrinsic - Pelvic lipomatosis
Urethra
o Intrinsic
Urethral stricture
Urethral valves
Urethral diverticula
Urethral atresia
Labial fusion
o Extrinsic - Benign prostatic hyperplasia and prostate cancer

2- Filling defect in IVP & hypoechoic mass in US:

-Blood clots
-Tumor
-Uric acid stones.
-IVP study done for a male & showed a filling defect in the renal pelvis non-radio opaque. U/S
shows echogenic structure & hyperacoustic shadow. The most likely diagnosis is:
a. Blood clot
b. Tumor
C. Uric acid stone
d. ???
- a non opaque renal pelvis filling defect is seen on IVP.Ultrasound reveals dense echoes and
acoustic shadowing.The MOST likely diagnosis is:
a)blood clot
b)tumor
c)sloughed renal papilla
d)uric acid stone
e)crossing vessel
Causes
Most research on the etiology and prevention of urinary tract stone disease has been directed toward the role of
elevated urinary levels of calcium, oxalate, and uric acid in stone formation, as well as reduced urinary citrate levels.
Hypercalciuria is the most common metabolic abnormality. Some cases of hypercalciuria are related to increased
intestinal absorption of calcium (associated with excess dietary calcium and/or overactive calcium absorption
mechanisms), some are related to excess resorption of calcium from bone (ie, hyperparathyroidism), and some are
related to an inability of the renal tubules to properly reclaim calcium in the glomerular filtrate (renal-leak
hypercalciuria).
Magnesium and especially citrate are important inhibitors of stone formation in the urinary tract. Decreased levels
of these in the urine predispose to stone formation.
A low fluid intake, with a subsequent low volume of urine production, produces high concentrations of stone-
forming solutes in the urine. This is an important, if not the most important, environmental factor in kidney
stone formation.
The exact nature of the tubular damage or dysfunction that leads to stone formation has not been characterized.
The most common findings on 24-hour urine studies include hypercalciuria, hyperoxaluria, hyperuricosuria,
hypocitraturia, and low urinary volume. Other factors, such as high urinary sodium and low urinary magnesium
concentrations, may also play a role. To identify these risk factors, a 24-hour urine profile, including appropriate
serum tests of renal function, uric acid, and calcium, is needed. Such testing is available from various commercial
laboratories. A finding of hypercalcemia should prompt follow-up with an intact parathyroid hormone study to
evaluate for primary and secondary hyperparathyroidism.

Imaging Studies
Plain abdominal radiography
o Plain abdominal radiography (also known as a flat plate or kidney, ureter, and bladder [KUB] radiography) is
useful for assessing total stone burden, as well as the size, shape, and location of urinary calculi in some
patients. It is also helpful in determining the progress of the stone without the need for more expensive tests with
greater radiation exposures.
o Calcium-containing stones (approximately 85% of all upper urinary tract calculi) are radiopaque, but pure
uric acid, indinavir-induced, and cystine calculi are relatively radiolucent on plain radiography.
o When used with other imaging studies, such as a renal ultrasonography or, particularly, CT scanning, the plain
film helps provide a better understanding of the size, shape, location, orientation, and composition of urinary stones
revealed with these other imaging studies. This may also be helpful in planning surgical therapy and in tracking
progress of the stone over time.
Renal ultrasonography
o Renal ultrasonography by itself is frequently adequate to determine the presence of a renal stone. The study is
mainly used alone in pregnancy or in combination with plain abdominal radiography to determine hydronephrosis or
ureteral dilation associated with an abnormal radiographic density believed to be a urinary tract calculus.
o A stone easily identified with renal ultrasonography but not visible on the plain radiograph may be a uric
acid or cystine stone, which is potentially dissolvable with urinary alkalinization therapy.
o Ureteral calculi, especially in the distal ureter, and stones smaller than 5 mm are not easily observed with
ultrasonography.
Intravenous urography
o An intravenous urography (IVU) test, also known as an intravenous pyelography (IVP), has been the standard for
determining the size and location of urinary calculi up until recently. IVU provides both anatomical and functional
information.
o IVU is very labor intensive and is no longer the standard for the initial evaluation of a patient with a kidney
stone. It may fail to reveal alternative pathology if a stone is not discovered, delaying the final diagnosis.
Up to 6 hours may be required to complete the study in the presence of severe obstruction.
For optimal results, IVU requires a bowel preparation.
It involves intravenous injection of potentially allergic and mildly nephrotoxic contrast material.
o A helical CT scan without contrast material is currently believed to be the best initial radiographic examination
for acute renal colic. If positive, KUB radiography is recommended to assist in follow-up and planning.
o The so-called delayed nephrogram on the IVU is one of the hallmark signs of acute urinary tract obstruction. The
relative delay in penetration of intravenous contrast passing through an obstructed kidney elicits this sign. The
kidney appears to develop a whitish color, and contrast appearance within the collecting system of the affected renal
unit is significantly delayed.

o IVU is helpful in identifying the specific problematic stone among numerous pelvic calcifications and in
establishing that the other kidney is functional. These determinations are particularly helpful if the degree of
hydronephrosis is mild and the non-contrast CT scan findings are not definitive. CT scanning with delayed contrast
series and thin slices has reduced the need for IVU in the evaluation of problematic ureteral stones.

3- a 75 year olf man came to the ER complaining of acute urine retention what will be your
initial management:
a)send patient immediately to OR for prostatectomy
b)empty urinary bladder by folley’s catheter and tell him to come back to the clinic
c)give him antibiotics because retention could be from sort of infection
d)insert folly’s catheter and tell him to come back to the clinic (b & d are repeated)
e)admission, investigation which include cystoscopy then..
- A 82 years old patient present with urinary retention. What is the most proper treatment in
ER?
-Insert Folly’s Cath then send to clinic.
-Insert Folly’s Cath then send to home.
-O.R. for prostatectomy.
-Admission, Investigation, then do cystoscope or TRUP.
- In an 82 years old patient with acute urinary retention,the management is:
a) To empty the bladder by Foley’s catheter and follow up in the clinic.
b) To insert a Foley’s catheter then send the patient home to come back in the clinic.
c) To admit and investigate by TURP.
d) Immediate prostatectomy
trans urethral resection of the prostate for benign prostate enlargement.
Asymptomatic pts do not require treatment, and
those with complications of urethral obstruction such as inability to urinate, renal failure, recurrent urinary tract
infection, hematuria, or bladder stones clearly require surgical extirpation of the prostate, usually by transurethral
resection (TURP). However, the approach to the remaining pts should be based on the degree of incapacity or
discomfort from the disease and the likely side effects of any intervention. If the pt has only mild symptoms,
watchful waiting is not harmful and permits an assessment of the rate of symptom progression. If therapy is desired
by the pt, two
medical approaches may be helpful: terazosin, an α1-adrenergic blocker (1 mg at bedtime, titrated to symptoms up
to 20 mg/d), relaxes the smooth muscle of the bladder neck and increases urine flow; finasteride (5 mg/d), an
inhibitor of 5 α-reductase, blocks the conversion of testosterone to dihydrotestosterone and causes an average
decrease in prostate size of ~24%. TURP has the greatest success rate but also the greatest risk of complications.
Transurethral microwave thermotherapy (TUMT) may be comparably effective to TURP. Direct comparison has not
been made between medical and surgical management.
4- premature-ejaculation, all true except:
a) most common sexual disorder in males
b) uncommon in young men
c) Benefits from sexual therapy involving both partners
d) it benefit from anxiety Rx
5- acute GN, all is acceptable Ix (investigations) except:
a) complement
b) urinanalysis
c) ANA
d) Blood culture
e) Cystoscopy
6- A 20 yr old female present with fever, loin pain & dysuria, management include all of the
following except:
a) urinanalysis and urine culture
b) blood culture
c) IVU (IVP)
d) Cotrimexazole
7- Old male came with urine retention, dilated ureter and hydronephrosis, Dx is:
a) Benign prostatic hyperplasia.
b) Ureteric stone impaction.
c) bladder tumor.
8- In Testicular torsion, all of the following are true, except:
a) Very tender and progressive swelling.
b) More common in young males.
c) There is hematuria.
d) Treatment is surgical.
e) Has to be restored within 12 hours or the testis will infarct.
Testicular torsion is a true urologic emergency and must be differentiated from other complaints of testicular pain
because a delay in diagnosis and management can lead to loss of the testicle. Though testicular torsion can occur at
any
age, including the prenatal and perinatal periods, it most commonly occurs in adolescent males; it is the most
frequent cause of testicle loss in that population.
Clinical
History
History includes a sudden onset of severe unilateral scrotal pain.
Onset of pain can occur more slowly, but this is an uncommon presentation of torsion.
Torsion can occur with activity, can be related to trauma in 4-8% of cases,2 or can develop during sleep.
The historical features suggestive of testicular torsion include the following:
o Acute onset of unilateral scrotal pain
o Scrotal swelling
o Nausea and vomiting: In the pediatric population, nausea and vomiting more commonly accompany acute
testicular torsion and have a positive predictive value of greater than 96%. 4
o Abdominal pain (20-30%)
o Fever (16%)
o Urinary frequency (4%)
Many patients have a history of recurrent scrotal pain that has resolved spontaneously. This history is highly
suggestive of intermittent torsion and detorsion of the testicle. Patients who complain of what sounds like torsion-
detorsion should be referred promptly to a urologist since patients with symptoms of intermittent torsion who
electively have surgical exploration are less likely to develop subsequent torsion and loss of the testicle. 5 Creagh et
al reported that acute torsion developed in 10% of patients with intermittent torsion while they waited for surgery. 6
Physical
The physical examination is useful, but imperfect, in diagnosing acute testicular torsion. 7
 The physical examination, moreover, may be difficult to perform, as the testicle is typically very tender and
patients are often in significant discomfort.

The involved testicle is painful and is frequently elevated in position when compared with the other side.
 Horizontal lie of the testicle - While abnormal lie can help diagnose testicular torsion, fewer than 50% of cases
demonstrated true horizontal lie.7

Enlargement and edema of the testicle; edema involving the entire scrotum
 Scrotal erythema

Ipsilateral loss of the cremasteric reflex - The cremasteric reflex is almost always absent in patients with testicular
torsion, and its presence may help to distinguish other causes of acute scrotal pain from testicular torsion. Case
reports, however, have noted the opposite to be true. 8,9,7
 Usually, no relief of pain upon elevation of scrotum (elevation may improve the pain in epididymitis [Prehn sign])

Fever (uncommon)

Causes
Congenital anomaly; bell clapper deformity
Undescended testicle
Sexual arousal and/or activity
Trauma
Testicular tumor
Exercise

Treatment
Emergency Department Care
Early diagnosis and prompt urologic consultation is essential since time is critical in salvage of the testicle.
Analgesic pain relief should be administered as testicular torsion is typically very painful.
Attempt manual detorsion with pain relief as the guide for successful detorsion. The procedure is similar to
the "opening of a book" when the physician is standing at the patient's feet.
Most torsions twist inward and toward the midline; thus, manual detorsion of the testicle involves twisting
outward and laterally.
o For example, in a suspected torsion of the right testicle, the physician is in front of the standing or supine patient
and holds the patient's right testicle with the left thumb and forefinger.
o The physician then rotates the right testicle outward 180° in a medial to lateral direction.
o Rotation of the testicle may need to be repeated 2-3 times for complete detorsion and to provide pain relief to the
patient.
o For the patient's left testicle, the physician uses the right thumb and forefinger and rotates the patient's left testicle
in an outward direction 180° from medial to lateral.
o Manual detorsion is successful in 26.5% to greater than 80% of patients based upon a number of reviewed
studies.2
Consultations
If the clinical diagnosis of torsion is suspected, early urologic consultation is mandatory since definitive treatment
is surgery for detorsion and orchiopexy or possible orchiectomy.
9- Epididymitis, one is true:
a)The peak age between 12 &18.
b)u/s is diagnostic.
c)The scrotal contents are within normal size.
d) typical iliac fossa pain.
e) none of the above.
- Epidydimitis:
A-Common at the age 12-18 years
B-Iliac fossa pain
C-Scrotal content does not increase in size.
D-Ultrasound will confirm the diagnosis.
E-All of above
Acute scrotal pain is a common complaint in the emergency room, and the diagnosis of epididymitis must be
differentiated from testicular torsion, a true scrotal emergency. 1 Ultrasonography is noninvasive and can help
differentiate between the pathologies. One area under investigation is the ability of emergency physicians to use
bedside ultrasonography to accurately diagnose patients with acute scrotal pain.
Epididymitis is most often due to the retrograde extension of organisms from the vas deferens and is rarely the result
of hematogenous spread. Bacterial infection results in the infiltration of WBCs into the epididymal connective
tissue, with resultant congestion and edema. This inflammation can rapidly spread to the tubules, with the risk of
abscess formation and necrosis of the epididymis.4,5 The causative organism is identified in 80% of patients and
varies according to the age of the patient.
Age
Epididymitis is primarily a disease of adults, most commonly affecting males aged 19-40 years.
Clinical
History
The progression of epididymitis usually is gradual in nature, with symptoms often peaking within 24 hours of onset.
Initially, the patient may note abdominal or flank pain because cellular inflammation typically begins in the vas
deferens. As the inflammation descends to the lower segment of the epididymis, the patient notes discomfort
localized to the scrotum. Younger patients or any patient with a sexually transmitted epididymitis may note
symptoms related to urethritis. A recent history of endourethral instrumentation or urinary tract infection is more
common in older patients. Symptoms include the following:
Scrotal pain and edema
Urinary frequency, urgency, or dysuria
Urinary retention from bladder outlet obstruction in older patients
Nausea
Fever and chills
Abdominal or flank pain
Bilateral epididymal involvement (10%)
Urethral discharge

Physical
Edematous tender epididymis: Early on, in cases without significant testicular involvement, tenderness may be
clearly localized to the epididymis.
Erythematous edematous scrotum
Scrotal abscess
o Scrotal fluctuance
o Scrotal fixation to underlying epididymis
Reactive hydrocele
 Prehn sign: This has been used to distinguish epididymitis from testicular torsion. Classically, scrotal elevation
decreases pain in epididymitis and not in torsion. However, the Prehn sign is not reliable for distinguishing
epididymitis from testicular torsion.
Urethral discharge (10%)
Fever or other constitutional symptoms with progression of disease
Causes
Epididymitis most often is due to the retrograde extension of bacterial organisms from the vas deferens.
o Prepubertal males - Coliform bacteria (E coli)
o Sexually active males -C trachomatis is the most common organism followed by N gonorrhoeae
o Older males - Coliform bacteria most common, sexually transmitted diseases less common
Less common causes of epididymitis include the following:
o Chemical epididymitis due to the reflux of sterile urine
o Boys with epididymitis due to a postinfectious inflammatory reaction to pathogens, such as M pneumoniae,
enteroviruses, and adenoviruses
o Candidal epididymitis in immunocompromised patients (AIDS)
o Epididymitis as an extrapulmonary manifestation of tuberculosis
o Epididymitis secondary to exposure to amiodarone therapy or prostate brachytherapy

10- benign prostatic hyperplasia, all are true except:

a) prostitis
b) nocturia
c) diminished size and strength of stream
d) haematuria
e) urine retention
- BPH all true except:
1) Prostits
2) Noctouria
3) Haematouria
4) Urine retention
5) Diminished size &strength of stream
-Benign prostatic hypertrophy can present with all, EXCEPT:
a) Nocturia.
b) Hematuria.
c) urinary retention.
d) poor stream.
e) prostatitis.
11- Patient oliguria one contraindicated:
a) l.V. ringer lactate
b) I.V.P
12- A no.20 French catheter is:
a) 20 cm long
b) 20 mm in circumference
c) 20 dolquais (French measurement) in diameter
d) 20 mm in diameter
e) 20 mm in radius
French catheter scale
Sizing scale of the French catheter system
The French scale or French gauge system (most correctly abbreviated as Fr, but also often abbreviated as FR or F)
is commonly used to measure the size (diameter) of a catheter. 1 Fr = 0.33 mm, and therefore the diameter of the
catheter in millimeters can be determined by dividing the French size by 3:
D (mm) = Fr/3
or
Fr = D (mm) × 3
For example, if the French size is 9, the diameter is 3 mm. Note that the French scale is a measurement of the
diameter, not the circumference (diameter × π).
An increasing French size corresponds to a larger-diameter catheter. This is contrary to needle-gauge size, where the
diameter is 1/gauge, and where the larger the gauge the narrower the bore of the needle.
The Stubs Iron Wire Gauge system is also commonly used in a medical setting, and is in fact more common for
measuring needles, even though many find the Stubs system to be more confusing because the scale is non-linear
and inversely proportional.
The French gauge was devised by Joseph-Frédéric-Benoît Charrière, a 19th-century Parisian maker of surgical
instruments, who defined the "diameter times 3" relationship.
In some countries (especially French-speaking), this unit is called Charriere and abbreviated as Ch.
Size Diameter Diameter
correspo (mm) (inches)
ndence
French
Gauge
3 1 0.039
4 1.35 0.053
5 1.67 0.066
6 2 0.079
7 2.3 0.092
8 2.7 0.105
9 3 0.118
10 3.3 0.131
11 3.7 0.144
12 4 0.158
13 4.3 0.170
14 4.7 0.184
15 5 0.197
16 5.3 0.210
17 5.7 0.223
18 6 0.236
19 6.3 0.249
20 6.7 0.263
22 7.3 0.288
24 8 0.315
26 8.7 0.341
28 9.3 0.367
30 10 0.393
32 10.7 0.419
34 11.3 0.445