UROLOGY

The prostate gland is made up of four zones. They are the peripheral, central, anterior fibromuscular stroma, and transition zones.

What is the most likely diagnosis?

a. Benign prostatic hyperplasia (BPH)

b. Prostatitis

c. Overactive bladder

d. Cystitis

e. Urethral stricture

Answer a. Benign prostatic hyperplasia (BPH)

BPH involves enlargement of the transitional zone of the prostate, leading to compression of the urethral canal which causes difficulty with the normal flow of urine. Prostatitis is an acute inflammatory condition characterized by pain and requires antibiotics. This patient’s symptoms are far too progressive to be an acute process. Overactive bladder syndrome is more common in women and is characterized by voiding eight or more times in a 24-hour period. Cystitis is an infection of the bladder leading to pyuria and suprapubic pain. A urethral stricture is caused by trauma or a sexually transmitted disease and would have to be mentioned in the history to be possible.

BPH involves hyperplasia, meaning an increase in the number of prostate cells, rather than hypertrophy, which involves a growth in the number of individual cells.

What is the best next step in the management of this patient?

a. Urinalysis (UA)

b. Urine culture (UC)

c. Blood urea nitrogen/creatinine (BUN/Cr)

d. Renal ultrasonography

e. All of the above

Answer e. All of the above

The proper workup for a patient with the clinical presentation of BPH is to check the UA, UC, and BUN/Cr. A UA and UC must be checked to assess for the presence of blood, leukocytes, bacteria, protein, or glucose. BUN and creatinine are important because BPH can lead to postobstructive renal insufficiency. Any anatomic abnormalities change the management of the patient.

The U.S. Preventive Services Task Force does not recommend routine screening with prostate specific agent (PSA) for prostate cancer.

Which of the following are indicated for this patient?

a. α1 Blockers

b. 5α-Reductase inhibitors

c. Lifestyle modifications

d. All of the above

Answer d. All of the above

The accepted medical therapies in patients with BPH include α1 blockers such as tamsulosin, and 5α-reductase inhibitors such as finasteride. Lifestyle modifications include decreasing the consumption of alcohol and caffeine-containing products. Avoidance of antihistamines, diuretics, decongestants, opiates, and tricyclic antidepressants should also be advised.

What is the best next step in the management of this patient?

a. Ultrasonography with postresidual urine volume measurement

b. Abdominal radiography

c. Intravenous (IV) urography

Answer a. Ultrasonography with postresidual urine volume measurement

Ultrasonography is the best next step in the management of any patient with BPH and elevation of the serum creatinine. Ultrasonography allows the volume measurement of the prostate and delineates whether the urethra is compromised. The measurement of a postresidual volume is an indicator of BPH. Normal postresidual volumes are less than 12 mL and are elevated in patients with BPH. Indications for IV urography include hematuria, a history of renal stones, urinary tract infection, or previous urinary tract surgery. Abdominal radiography will not show soft tissue enlargement.

What is the best next step in the management of this patient?

a. Transurethral incision of the prostate (TUIP)

b. Transurethral resection of the prostate (TURP)

Answer b. Transurethral resection of the prostate (TURP)

In patients with BPH that is not responding to medical therapy or in patients with renal compromise caused by postobstructive nephropathy, the best next step in the management of the patient is TURP. TUIP is used in patients who are not good candidates for a TURP because of comorbidities.

TURP causes ejaculations that are dry, and the man becomes sterile.

What is the most likely diagnosis?

a. Nephrolithiasis

b. Renal artery embolus

c. Pyelonephritis

d. Lumbosacral strain

e. Testicular torsion

Answer a. Nephrolithiasis

The acute onset of severe flank pain radiating to the groin with hematuria indicates renal stones. The pain waxes and wanes as the stone continues to pass from the kidney into the ureteral system. Hematuria is common. This can be either gross or microscopic. Testicular torsion is acute but presents with severe pain that starts in the scrotum. Pyelonephritis has costovertebral tenderness (CVA) and flank pain as well as fever and dysuria. Renal artery embolus presents with flank pain, and the patient has a history of recent cardiac catheterization or atrial fibrillation. Lumbosacral strain is simply back pain that you can elicit with palpation. Hypertension is not specific enough to be useful. Anything that causes pain can lead to hypertension.

What is the most accurate diagnostic test for this patient?

a. Ultrasonography of the kidneys

b. Kidney, ureters, and bladder (KUB) radiography

c. Computed tomography (CT) scan without contrast

d. CT scan with contrast

e. Intravenous pyelography

f. Magnetic resonance imaging (MRI) of the abdomen

g. Urine analysis

Answer d. CT scan without contrast

The best test to evaluate for a kidney stone is a CT scan of the pelvis without contrast. Ultrasonography is less accurate than a CT scan and is only used in pregnant patients presenting with nephrolithiasis. Calcium-containing stones are radiopaque, but pure uric acid, indinavir-induced, and cysteine calculi are radiolucent on plain radiography. Contrast is contraindicated because the patient may already have renal compromise and a decreased glomerular filtration rate. Intravenous pyelography is always the wrong test and is no longer done; it is analogous to the Schilling test of urology. MRI of the abdomen is also always the wrong answer in acute management of any abdominal process. A urine analysis is needed to corroborate the findings and confirm hematuria.

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