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Multiple
choice questions 1. answer C At least 10
million Americans suffer from urinary incontinence. In the neurologically intact individual the most common
subtypes are stress incontinence, which occurs with coughing or lifting; urge
incontinence, which occurs when patients sense the urge to void but are unable
to inhibit leakage long enough to reach the toilet; and overflow incontinence,
when the bladder cannot empty normally and becomes overdistended.
The term functional incontinence is applied to those cases where lower
urinary tract function is intact but other factors such as immobility and severe
cognitive impairment lead to incontinence. This patient
has mild urge incontinence. The first approach to control of this problem should
be behavioral. In a mild case such as this, a cure can be expected.
Success rates have ranged from 30% to 90% in published studies.
For more severe cases, various pharmacologic agents, including
anticholinergics, are useful. Failure
of these modalities should lead to urodynamic testing and consideration of
surgery. Ref:
Busby-Whitehead J, Johnson TM: Urinary incontinence.
Clin Geriatr Med 1998; 14 (2):285-296. 2) Hazzard WR, Blass JP, Ettinger WH Jr, et al (eds) :
Principles of Geriatric Medicine and Gerontology, ed 4. McGraw-Hill, 1999, pp
1597-1613. 2.
Answer B Women who present with
symptoms of acute dysuria, frequency, and pyuria do not always have bacterial
cystitis. In fact, up to 30% will
show either no growth or insignificant bacterial growth on a midstream urine
culture. Most commonly these
patients represent cases ofr sexually transmitted urethritis caused by Chlamydia
trachomatis, Neisseria gonorrhoeae, or herpes simplex virus. In this case, the gradual
onset, absence of hematuria, and week-long duration of symptoms suggest a
sexually transmitted disease. A history of a new sexual partner or a finding of
mucopurulent cervicitis would confirm the diagnosis.
Empiric treatment with a tetracycline and a search for other sexually
transmitted diseases would then be indicated.
Another possible diagnosis
is urinary tract infection with Escherichia coli or Staphylococcus species;
however, the onset of these infections is usually abrupt and accompanied by
other signs, such as suprapubic pain or hematuria.
Candida is unlikely because there is no accompanying discharge or
itching, and the patient's symptoms predated the use of antibiotics. Ref: Novak’s gynecology
2) Taylor’s family medicine text 3. Answer D Bacterial and interstitial
cystitis share several common features, including symptoms of urinary frequency,
urgency, and hematuria. On physical examination both diseases can be associated
with suprapubic tenderness. However,
on cystoscopic examination Hunner’s ulcer and glomerulations are seen in
interstitial cystitis. 4.
answer B Over 4% of boys have an
undescended testis at birth. The
incidence is higher in premature infants. The majority of undescended testes spontaneously descend
before the age of 3 months. If the testis has not descended by 6 months of age
in a term infant, it will remain undescended. Infertility and testicular
malignancy are associated with undescended testes.
The risk of testicular malignancy is thought to be 4-10 times higher in
patients with a history of an undescended testis, and higher still in those with
bilateral undescended testes, compared to the general male population.
Orchiopexy does not reduce the risk of testicular cancer, which peaks
between 15 and 45 years of age. Hormonal
treatment with LH-RH or hCG, used in Europe, has not been shown to be effective
in randomized, controlled trials in the United States.
Orchiopexy between 9 and 15 months is the recommended treatment for
undescended testes. After
orchiopexy, fertility is maintained in 85% of unilateral cases and 50%-65% of
bilateral undescended testes. Ref: Behrman RE, kliegman
RM, Jenson HB (eds): Nelson Textbook of Pediatrics, ed 16.
WB Saunders Co, 2000, pp 1650-1651. 5.
Answer: C Testicular torsion is the
most common cause of spontaneous testicular pain in boys age 12 years and older
and is uncommon before 10 years of age. There is inadequate fixation of the testis within the
scrotum, resulting in excessive mobility. Shortly
after torsion, there is acute pain and swelling of the scrotum, which is very
tender. The normal cremasteric
reflex is nearly always absent. The
differential diagnosis includes strangulated inguinal hernia, which most often
causes inguinal swelling, unlike torsion. There is no antecedent association of hydrocele with
testicular torsion. Spermatogenesis can be lost
within 6 hours of the loss of blood flow, making prompt diagnosis and surgical
detorsion and fixation essential. Either a 99mTc-pertechnetate flow scan or
color Doppler ultrasonography is about 95% accurate in determining flow, but
results can be misleading if torsion is less than 360 degrees. These tests are
reasonable, but should not delay surgical intervention given the small window of
therapeutic opportunity. 6.
Answer: D If a vas cannot be located
by an experienced surgeon, the possibility of congenital absence of the vas must
be considered. This is usually
associated with agenesis of the ipsilateral kidney.
The vas which can be palpated should be ligated, and a semen specimen
checked at the usual time. 7.
Answer A 8.
ANSWER: E This
man is experiencing the Jarisch-Herxheimer reaction – an acute, transient,
febrile reaction that occurs within the first few hours after treatment for
syphilis. The illness peaks at 6-8
hours and disappears within 12-24 hours after therapy.
Temperature elevation is usually low-grade and there is often associated
myalgia, headache, and malaise. It
is usually of no clinical significance and may be treated with salicylates.
The pathogenesis of the reaction is unclear; may be due to liberation of
antigens from the spirochetes. Ref:
Woodward et al, American Family Physician 1999; Cecil textbook of medicine,
2000. 9.
Answer: E The
majority of kidney stones are calcium oxalate stones. Individuals whose
occupations lead to decreased bathroom access and decreased fluid intake are at
increased risk. Dietary factors
that are modifiable risk factors include excessive intake of sodium, protein,
and oxalate, along with decreased fluid intake.
Calcium restriction is not useful. Workup of the initial episode of
stones includes CBC, BUN, Cr, uric
acid, phosphate levels, along with a UA. U/S
or helical CT is usually done after the stone has passed to screen for
polycystic kidney disease or asymptomatic staghorm calculus.
A 24-h urine collection of measurement of important analytes is usually
reserved for recurrent stone formers. Preventive
therapy with thiazide diuretics decreases urinary calcium, whereas drugs such as
triamterene, sulfonamides, carbonic anhydrase inhibitors, and indinavir increase
stone formation. Sodium restriction
is recommended, and beverages such as beer and tea (thought to increase urinary
oxalate excretion) may actually protect against stone disease.
The most important aspect of stone prevention is increased urinary
volume, so a daily ingestion of at least 2.5-3 liters of fluid is recommended. Ref:
Goldfarb et al. American Family Physician, 1999. 10.
Answer: B BPH
is common in men after 50. Symptoms
include a weak or interrupted urinary stream, a feeling of incomplete bladder
emptying, delays or hesitation in urination, urinary frequency, and urinary
urgency. Sympathetic blockade with
alpha blockers, such as terazosin and prazosin, provides rapid relief of some
symptoms. Medications that decrease
androgens (finasteride) and increase estrogens (DES) can lead to atrophy of the
epithelium, and over several months can result in symptomatic improvement.
Chlorpheniramine maleate and other antihistamines tend to increase
bladder neck muscle tone, worsening symptoms rather than relieving them. Ref:
Harrison’s Principles of Internal Medicine, 1998. 11.
Answer: A A
hydrocele of the tunica vaginalis testis occurs frequently at birth but usually
resolves in a few weeks or months. No treatment is indicated during the first year of life
unless there is a clinically evident hernia.
A simple scrotal hydrocele without communication with the peritoneal
cavity and no associated hernia should be excised if it has not spontaneously
resolved by the age of 12 months. Aspirating
the mass for diagnostic or therapeutic reasons is not recommended, since a loop
of bowel may be injured; removing the fluid is ineffective. Ref:
Nelson Textbook of Pediatrics. 12. Answers:
A) T; B) T; C) T; D) F Ref:
Mayo Clinic Proceedings 1996 13. Answers: A) F ; B) F;
C) T; D) F; E) F 14.
Answers : One
half to two-thirds of vasctomized men develop antisperm antibodies.
Initial concerns were that circulating immune complexes containing these
antibodies might damage the inner walls of coronary arteries.
However, carefully controlled studies of large studies of large groups of
vasectomized men have shown no association between vasectomy and CAD.
In fact, with the exception of congestive epidimytis/orchitis, the
incidence of all diseases among vasectomized men is similar to or lower than
that of paired controls. Impotence rarely occurs in men who have received adequate
preoperative counseling, and is no more prevalent than in non-vasctomized men.
Sperm granuloma presenting as a nodular swelling may be a secondary
response to leakage from the severed end of the proximal vas.
Patients with sperm granulomas may be at increased risk for
recannulization and should have periodic semen analysis. Ref:
Goroll, Primary Care Medicine 1995. Rakel,
Textbook of Family Practice 1995. 15.
Answers A)
true Answers:
16) F; 17) F; 18) T; 19) T; 20) F; 21) F; 22) T; 23 )T; 24)F; 25) T; 26)
T; 27) F; 28) F. Distal
ureteral calculi smaller than 4 mm have at least a 50% chance of passing
spontaneously; therefore, urologic consultation is not necessary in this
setting. A noncontrast spiral CT
scan is now probably the imaging study of choice when available, replacing
intravenous pyelography. MRI
studies are not useful in the workup of a kidney stone. A metabolic
workup is indicated for patients with recurrent stones.
A 24-hour urine collection for sodium, calcium, uric acid, citrate, and
oxalate is generally recommended, along wiith serum calcium, phosphorous,
creatinine, and uric acid levels. A
parathyroid hormone level is not indicated unless hypercalcemia is demonstrated.
A 24-hour urine cystine study is not indicated since the case involves a
calcium oxalate stone. Hyperuricosuria
is associated with calcium stones. Treatment
with allopurinol and potassium citrate can be beneficial.
All stone formers can probably benefit from high fluid intake and a
low-sodium diet. Nuts and leafy green vegetables should be restricted in this
patient because they contain oxalate. Thiazide
diuretics are indicated in certain types of hypercalciuria, but not in
hyperuricosuria. Probenecid
increases uric acid urine secretion, and therefore is contraindicated. Ref:
Zieve PD: Handbook of ambulatory Medicine.
Williams and Wilkins, 1995,
pp218-233. 2) Tanagho EA, McAninch
JW (eds): Smith’s General Urology, ed
15. Lange Medical Books, 2000, pp
218-233. 16. Answer C The initial treatment of choice for prostate carcinoma metastatic to bone is hormonal manipulation. There is controversy regarding the merits of estrogen therapy versus therapy with bilateral orchiectomy or the combination of estrogen plus castration. Radical prostatectomy, radiation, and chemotherapy are not indicated as initial therapy. Supportive treatment alone cannot be justified, as hormonal treatment can be quite effective. 17. Answer B Concomitant use of nitrates with sildenafil is contraindicated since sildenafil potentiates the vasodilatory effect of circulating nitric oxide, resulting in a significant potentially fatal fall in blood pressure. 18. Answer D the impotent male who demonstrates elevated serum prolactin and depressed or normal serum testosterone must be evaluated for a pituitary tumor. Although isolated hyperprolactinemia can cause impotence through unknown mechanisms, it is important to rule out a prolactin-secreting pituitary microadenoma. Radiologic studies, starting with a plain skull radiographs and progressing toward a CT or MRI scan, are the most useful tools for diagnosing pituitary tumors. At this point in the case described, there is not enough information to warrant any of the other tests. 19. Answer B Anticholinergic drugs with atropine-like action include an umber of antiparkinsonian drugs, the tricyclic antidepressants, and many atipsychotic agents. Anticholinergic effects chiefly cause problems with arousal disorders, secondary to their parasympatholytic action. This is manifested in men as erectile problems. 20. Answer A Prostate cancer is the most frequent malignancy in elderly men and the most prevalent carcinoma in the male population. The most common presentation of prostate cancer is the discovery of an asymptomatic nodule in the prostate gland of an older man during rectal examination. Contrary to the belief of many physicians, the majority (60%) of asymptomatic nodules in the prostate are malignant. Non-neoplastic nodular enlargement of the prostate (benign prostatic hypertrophy) arises in the inner (periurethral) group of prostatic glands commonly referred to as the "female" prostate. For this reason, benign enlargement produces many urinary symptoms. Prostatic cancer almost invariably begins in the outer group of glands referred to as the "male" prostate. Nodules associated with benign prostatic hypertrophy typically are smooth and not stony hard like cancers. Microscopically, over 95% of malignant neoplasms of the prostate are adenocarcinomas. Sarcomas of the prostate are uncommon tumors that constitute approximately 0.1% of all primary neoplasms of the prostate gland. Nodules of the type described are not a feature of chronic prostatitis. A normal serum PSA level does not rule out prostate cancer and can occur in up to 20% of men diagnosed with this disease. 21. Answer C Undescended testes occur in about 1%-2% of full-term males, and up to 30% of preterm males. Although undescended testes are generally histologically normal at birth, they begin to atrophy after 1 year and may undergo malignant degeneration in the third or fourth decade of life if not relocated in the scrotum. Hormonal treatment with hCG may be effective in treating retractile testes, but not truly undescended testes. Spontaneous descent of the testis does not occur after 1 year of age, and orchiopexy is recommended early in the second year of life if the testis has not descended by 1 year of age. 22. Answer D Stress incontinence is common in older women. It occurs when the bladder's internal sphincter is unable to keep the bladder neck closed against the rise in intravesicular pressure resulting from normal activites. While only small amounts of urine may be lost with each episode, the cumulative effect can severely impair a patient's quality of life. Nonpharmacologic therapy is important in the treatment of stress incontinence. Adjusted voiding intervals and pelvic floor (Kegel) exercises can be helpful, for example. The tone of the internal sphincter of the bladder is modulated through α-adrenergic receptors. Stimulation of these receptors with agents such as pseudoephedrine or imipramine can increase internal sphincter tone and alleviate symptoms. Tolterodine, flavoxate, and hyoscyamine reduce bladder contractions and are potentially helpful to patients with urge incontinence from detrusor overactivity. Bethanechol is a bladder stimulant and may be helpful in patients with transient urinary retention and overflow incontinence due to decreased detrusor tone. 23. Answer C Prostate cancer is the second most common cause of cancer death in men. African-Americans are 1.5 times as likely as whites to develop prostate cancer. A family history of prostate cancer in a first degree relative also increases the risk. No risk association has been demonstrated for other racial or ethnic groups. 24. Answer C The American Academy of Pediatrics has published clinical guidelines for treating infant and young children (2-24 months) with a febrile urinary tract infection (UTI). They recommend ultrasonography in all these children following the first episode of febrile UTI, as well as either voiding cystourethrography or radionuclide cystography to rule out vesicourethral reflux (VUR). More than 50% of these children will have some VUR on these studies, and the degree of VUR correlates with renal parenchymal damage. All children should have urine for culture collected by suprapubic aspiration or urethral catheterization. The perineal bag has unacceptable rates of contamination, especially in girls and uncircumcised boys. A 7- to 14-day course of parenteral or oral antibiotics is recommended, with prophylactic oral antibiotics recommended until imaging studies are completed. 25. Answer A The process of aging is associated with both benign and malignant alterations or changes of the prostate gland, but in most men these will remain undiscovered at the time of death. The incidence and mortality rate for prostate cancer have declined over the past few years. Screening for prostate cancer has not proven effective in prospective randomized trials. Prostate cancer is the most common of all cancer diagnoses, and is the second leading cause of cancer death in men. 26. Answer A Hemophilia is X-linked and occurs in approximately 1 in 5000 male births, with 85% having factor VIII deficiency (hemophilia A) and the remaining 15% having factor IX (hemophilia B) and factor XI (hemophilia C) deficiency. Because factor VIII does not cross the placenta, bleeding symptoms may be present from birth, with the most dreaded manifestation being intracranial hemorrhage. About 30% of affected male infants will bleed from the circumcision site. The only "routine" laboratory test that is affected by a reduced level of factor VIII is the activated partial thromboplastin time. Once hemophilia is suspected, the specific assay for factor VIII will confirm the diagnosis. Factor VIII levels in affected persons vary from less than 1% to approximately 25% of normal activity. Clinical severity of the disease for treating patients with hemophilia can help prevent transfusion-related infections. Deficiencies of antithrombin III, protein S and protein C, and mutations of the gene for factor V (factor V Leiden) are associated with thrombotic conditions, not bleeding. 26. Answer D Indwelling catheter placement, while adding the risk of urinary infection, is most likely to provide immediate relief of this patient's urinary retention. It will minimize or prevent further contamination of his decubitus ulcer with urine. Prostatectomy may relieve the urethral obstruction, but he is likely to remain incontinent due to his vascular dementia. Doxazosin of finasteride would likely be inadequate in this situation. Tolterodine is not indicated for overflow incontinence. 27. Answer A Asymptomatic bacteriuria is defined as the presence of more than 100,000 CFU/mL of voided urine in persons with no symptoms of urinary tract infection. The largest patient population at risk for asymptomatic bacteriuria is the elderly. Up to 50% of elderly men and women may have bacteriuria without symptoms. Although early studies noted an association between bacteriuria and excess mortality, more recent studies have failed to demonstrate any such link. In fact, aggressively screening elderly persons for asymptomatic bacteriuria and subsequent treatment of the infection has not been found to reduce either infectious complications or mortality. Consequently, this approach is not recommended. |
