Urology:  Pre-test

Multiple choice, choose one best answer

1.  A 70-year-old white female complains of two episodes of urinary incontinence.  On both occasions she was unable to reach a bathroom in time to prevent loss of urine.  The first episode occurred when she was in her car and the second while she was in a shopping mall.  She is reluctant to go out because of this problem.

The most likely cause of her problem is

a.  overflow incontinence

b.  stress incontinence

c.  urge incontinence

d.  functional incontinen ce

2. A 20 yr old white female presents with painful and frequent urination of gradual onset over the past week.  She has never had a urinary tract infection.  There is no associated hematuria, flank pain, suprapubic pain, or fever.  There is no itching or vaginal discharge.  A midstream urine specimen taken earlier in the week showed significant pyuria but a culture was reported as no growth.  She has taken an antibiotic for 2 days without relief.  Her only other medication is an oral contraceptive agent.

Which one of the following is the most likely infectious agent?

a.  Escherichia coli

b.  Chlamydia trachomatis

c.  Candida albicans

d.  Staphylococcus saprophyticus

3. Which one of the following distinguishes acute bacterial cystitis from interstitial cystitis?

a.  Gross hematuria

b.  Urinary urgency and frequency

c.  Suprapubic tenderness

d.  Cystoscopic findings

4.     While examining a male infant during a routine well child visit, you palpate only one testicle within the scrotum.  Which of the following is true concerning this problem?

a.  Surgery should be postponed until three years of age to allow for spontaneous descent
b.  The risk of malignancy in the undescended testis is several times higher than in the general population
c.  Orchipexy with antecedent hormonal therapy (LH-RH, hCG) is the currently recommended treatment
d.  Orchipexy eliminates the risk of testicular malignancy
e.  In spite of orchipexy, more than 50% of patients with a history of undescended testis are infertile as adults

5.     Which of the following is true regarding testicular torsion?

a.  It is most common in boys under the age of 10
b.  The cremasteric reflex is usually present
c.  Surgical exploration and detorsion must be done within 6 hours of in order to preserve testicular function
d.  Testicular scanning is necessary prior to surgical exploration in order to document blood flow to the testis
e.  Testicular torsion is often preceded by a communicating hydrocoele

6.     While performing a vasectomy on a 33 year old male, you are unable to definitely identify the left vas deferens.  You take some time to try and find the vas, but the patient is becoming very uncomfortable.  You can easily locate the right vas.  The patient has fathered three children and has had no difficulty with erectile function.  The examination of the external genitalia was normal. 

       What should you do next?

a.  Recommend that you try and find the left vas deferens under general anesthesia
b.  Abandon the attempt at vasectomy and recommend a tubal ligation for his wife
c.  Make a large scrotal incision and continue to find the left vas deferens
d.  Ligate the right vas deferens and check a semen sample in 6 weeks.

7.     What is depicted in the following diagram?

a.  Varicocele
b.  Hydrocele
c.  Epdidymitis
d.  Normal anatomy

8. A 25-year old male visits your office concerned about a painless ulcer on the glans of his penis.  After appropriate examination and testing you diagnose primary syphilis and treat him with 2.4 mill units of benzathine penicillin IM in a single dose.  Eight hours later, while you are working the evening clinic, he returns because he has a fever of 100.6 and a bad headache, which he rarely gets.  He says he “aches all over”.

Which is the most appropriate action at this time?

a.  Obtain three blood cultures from different sites at 30-minute intervals

b.  Order a CT scan of his head

c.  Perform a spinal tap

d.  Add doxycycline 100 mg po bid for 14 d

e.  Reassure and prescribe antipyretics

9. A 55-yr old construction worker with no history of health problems develops intense flank pain with radiation into the groin.  UA shows hematuria but is otherwise negative.  He subsequently passes a stone which is analyzed and shown to consist of calcium oxalate.  A CBC and chem profile are negative.

Which of the following is true in this situation?

a.  The patient should be started on triamterene

b.  Beverages such as beer and tea should be avoided

c.  Dietary calcium should be restricted

d.  A 24-hour urine specimen should be checked for calcium

e.  Daily ingestion of 3L of fluid should be recommended

10. A 53 year old white male complains of difficulty urinating.  He says that his urinary stream seems weak and that his bladder does not feel empty after he finishes voiding.  Your examination reveals only a mildly enlarged, otherwise normal prostate gland.

Which of the following will provide the quickest relief  of his symptoms?

a.  finasteride

b.  terazosin

c.  chlorpheniramine

d.  diethylstilbestrol

11.  During a well child exam of a healthy-appearing 4 week old male born at term, his mother questions you about a prominence in the left side of his scrotum, which  she has noted since his baths were begun.  Your physical examination reveals an oblong, nontender, nonreducible, light-transmitting mass closely adhered to or involving the testis.

You should recommend which of the following?

a.  Further observation

b.  Sterile aspiration of the mass

c.  Immediate surgery

d.  Surgery in 3-4 months

MULTIPLE TRUE-FALSE (mark true or false for EACH answer)

12. Effective management options in children with nocturnal enuresis include which of the following? (MARK EACH ANSWER TRUE OR FALSE)

a.  imipramine (tofranil)

b.  desmopressin acetate (DDAVP)

c.  Behavioral modification with an enuretic alarm

d.  A 3-week course of broad-spectrum antibiotics

13. A 42-year-old Hispanic male presents to your office with flank pain and hematuria.  He ahs a history of passing two kidney stones in the last two years but the stones were not sent for analysis.  You treat him with analgesiscs and suggest that he strain his urine.  He returns the following day having recovered the stone, and analysis shows it is calcium oxalate.

  Appropriate treatment options include which of the following? (MARK EACH ANSWER TRUE OR FALSE)

a.  fluid restriction of 1200 cc daily

b.  furosemide (lasix) 40 mg daily

c.  hydrochlorothiazide (Hydrodiuril), 25 mg daily

d.  verapamil (calan), 240 mg daily

e.  vitamin D, 2000 units daily

14.  You plan to perform a vasectomy on a 35-year old white male.  Prior to the procedure, he asks you about its side effects.

You tell your patient that as a result of his vasectomy, he is at higher risk to (MARK EACH ANSWER TRUE OR FALSE)

a.  Die of ischemic heart disease

b.  Become impotent

c.  Produce antisperm antibodies

d.  Suffer from congestive epididymitis

e.  Develop sperm granuloma

15.  Detrusor overactivity (urge incontinence) is… (MARK EACH ANSWER TRUE OR FALSE)

a.  A frequent cause of urinary incontinence in the elderly population

b.  Characterized by urinary urgency and frequency

c.  Seen in patients with CNS disorders

d.  Characterized by a distended bladder

e.  Most effectively treated by estrogen therapy.

Clinical set problem:

The next several questions refer to the case below.  Mark TRUE or FALSE for EACH question.

A 33 year-old white male presents to your office with colicky flank pain radiating into a testicle.  His symptoms are similar to those he had when he passed kidney stones on two occasions in the past 3 years. He was treated in emergency departments both times and never came in for follow-up evaluations. His history and physical findings are otherwise unremarkable.

A KUB done on the same day demonstrates a 3-mm radiopaque calculus in the distal third of the right ureter. Further management at this time should include

16. a renal MRI

17. urology referral for stone extraction

Analysis of the stone shows it to be calcium oxalate.  Appropriate studies to obtain at this point include

18. serum calcium

19. 24-hr urine for citrate, calcium, and oxalate

20. 24-hr urine cystine

21. parathyroid hormone

You order a 24-hr urine for uric acid wihich is elevated.  All other metabolic studies are normal.

Appropriate management would include

22. encouraging large intakes of fluid on a regular basis

23. a low-sodium diet

24. a thiazide diuretic

25. potassium citrate

26. allopurinol (Zyloprim)

27. probenecid (Benemid)

28. a diet rich in nuts and leafy green vegetables

29.  Which one of the following is the preferred INITIAL treatment for       symptomatic prostate carcinoma metastatic to multiple bones?

a.  Radical prostatectomy 

b.  Radiation therapy

c.  Hormonal manipulation

d.  Chemotherapy

e.  Supportive treatment only

30.   Deaths have been associated with the concomintant use of sildenafil (Viagra) and which class of agents?

a.  Sulfonylureas

b.  Nitrates

c.  Beta-adrenergic blockers

d.  Proton pump inhibitors

e.  Leukotriene formation inhibitors

31. In working up a 48-year-old white male for impotence, you find that he has a serum prolactin level of 160 ng/ml (N2-15) and a serum testosterone level of 300 ng/lm (N300-1100).  It would now be appropriate to order

a.  A testicular biopsy

b.  A glucose tolerance test

c.  A 24-hour urine for 17-kerosteroids

d.  An MRI scan of the head

e.  A buccal smear

32. Anticholinergic drugs primarily affect which phase of the sexual response cycle?

a.  Desire

b.  Arousal

c.  Orgasm

d.  Resolution

33.  A 68-year-old African-American male is found to have an asymmetric, hard, 1-cm nodule of the prostate gland on routine examination.  He denies symptoms of urinary outlet obstruction or constitutional symptoms such as weight loss or sweating.  The remainder of his physical examination is normal and his serum prostate-specific antigen (PSA) level is normal.

Appropriate management at this point includes which of the following?

a.  Referral for biopsy of the nodule

b.  A repeat digital rectal examination in 1 year

c.  A repeat PSA level in 3 months

d.  Terazosin (Hytrin)

e.  Finasteride (Proscar)

34.  A male infant is noted at birth to have a unilateral undescended testis. Orchiopexy is recommended if the testis has not descended by what age?

a.  2 weeks

b.  3 months

c. 12 months

d.  2 years

e.  4 years

35.     A 73-year-old white female presents to the office with her daughter.  She complains of a several-year history of intermittent involuntary loss of urine which is gradually worsening.  She frequently loses small amounts of urine when she rises from a low chair, and greater amounts if she coughs, sneezes, or laughs.  She has taken to wearing absorbent undergarments and admits to significant embarrassment and limitation of activities as a result of her problem.  Her daughter states that the patient has gradually withdrawn from her usual social contact.

Physical examination reveals a well-appearing elderly female.  Her pelvic examination shows mucosal atrophy and a mild cystocele.  With a full bladder, she loses a few mL of urine into a gauze pad when standing and coughing.  Her post-void residual is normal.  Her physical examination is otherwise normal for her age, and her urinalysis is normal.

If nonpharmacologic interventions are not completely successful in the management of this patient's problem, which one of the following medications is most likely to help?

a.  Bethanechol (Urecholine)

b.  Flavoxate (Urispas)

c.  Hyoscyamine (Anaspaz NuLev)

d.  Pseudoephedrine

e.  Tolterodine (Detrol, Detrol LA)

36.      Which one of the following groups is at increased risk for prostate cancer?

a.  Whites

b.  Hispanics

c.  African-Americans

d.  Native Americans

e.  Asian-Americans

37.       Which one of the following is true regarding urinary tract infections in febrile infants and young children (age 2-24 months)?

a.  A perineal bag should be used to collect urine for cultures

b.  A 3-day course of oral antibiotic therapy is appropriate

c.  Ultrasonography should be performed after the first febrile UTI

d.  Voiding cystourethrography or radionuclide cystography should be performed only after recurrent UTI.

e.  Prophylactic antibiotics should be continued for 1 year in all children after the first febrile UTI.

38.     In healthy adults, performance on the Folstein Mini-Mental State Examination is affected by which one of the following?

a.  Educational attainment

b.  Socioeconomic status

c.  Gender

d.  Race

39.     A mother of a 5-day-old white male brings the infant to your office because of profuse bleeding from his circumcision site.  A plastibell technique was used, and the bell is partially on. The mother reports that there was some scrotal bruising after the procedure.  The remainder of the pre- and postnatal history is unremarkable.  The infant appears healthy and vigorous.  There is no heart murmur.  Capillary refill is good.  There is no bruising and no petechiae.

                Laboratory Findings

                Hematocrit: 54% (N 41-65)

                Hemoglobin: 18.0 g/dL (N 13.4-19.8)

                WBCs: 14,000/mm3 (N6000-17,500)

                Platelets: 278,000/mm3 (N 150,000-400,000)

                Prothrombin time 12 sec (N 10-16)

                Activated partial prothrombin time 87 sec (N 31-54)

Which one of the following additional tests will most likely help you to make the correct diagnosis?

a.  Factor VIII level

b.  Hemoglobin electrophoresis

c.  Antithrombin III level

d.  Protein S and protein C levels

e.  Testing for factor V Leiden

40.     You are asked to see an 88-year-old male nursing-home patient, who is having problems with constant overflow incontinence.  Intermittent catheterization has proven difficult, due to urethral obstruction and his resistance to such procedures.  He has dementia and generalized weakness due to multiple strokes and is bedbound, requiring total care for most activities of daily living.  Examination shows a grade 3 coccygeal ulcer that has been present for several moths, and a digital rectal examination demonstrates a large, irregular prostate.

Which one of the following is the best choice to quickly correct his incontinence, thereby assiting in healing his decubitus ulcer?

a.  Doxazosin (Cardura)

b.  Finasteride (Proscar)

c.  Tolterodine (Detrol)

d.  Long-term indwelling Foley catheter placement

e.  Referral for transurethral prostatectomy

41.      A healthy 75-year-old female brings the results of a urinalysis and subsequent culture obtained prior to scheduled cataract surgery.  The urinalysis reveals 1-2 WBCs, 0-1 RBCs, a few epithelial cells, and 4+ bacteria.  The culture shows > 100,000 Escherichia coli.  She denies urinary symptoms.  Her only medication is hydrocholorothiazide (Hydro DIURIL), which has controlled her blood pressure.

          Which on of the following should you do?

a.  Inform her that treatment is not necessary

b.  Prescribe a 10-day course of amoxicillin

c.  Order measurement of post-void residual volume and 7 days of trimethoprim/sulfamethoxazole (Bactrim, Septra)

d.  Refer her to a urologist for evaluation

Test