75 y/o male with history of benign prostatic hypertrophy, but otherwise healthy, presents with acute onset suprapubic pain and difficulty urinating. Foley catheter is placed and drains 900 cc of urine. Should renal failure or postobstructive diuresis be of concern?

No.  Renal failure and postobstructive diuresis are of concern in chronic urinary obstruction which often presents with no or minimal abdominal pain.


Source

Barrisford, G.  et al.  "Acute urinary retention"  Up to Date.  May 2011.

What characteristics of the clinical evaulation and urinalysis suggest a glomerular (nephrological), as opposed to a nonglomerular (renal pelvis, ureter, bladder, etc), cause of hematuria?

• 2+ or greater proteinuria 
• RBC casts
• presence of at least 80% dysmorphic RBCs
• elevated blood pressure

If the clinical evaluation and urinalysis suggest a glomerular cause of hematuria, then renal function should be measured and nephrology consult considered.


Source

Jimbo, M.  "Evaluation and Management of Hematuria"  Prim Car Clin Office Pract.  2010. 

What is the likelihood of normal erectile function after penile fracture?

Those undergoing surgical repair within 8 hours of injury have an excellent prognosis with almost all having return of normal erectile function.


Source

Wein: Cambell-Walsh Urology, 9th ed.

What are the indications for surgical exploration after blunt scrotal trauma?

• testicular rupture
• large hematocele 
• traumatic torsion 
• testicular dislocation 

Testicular salvage rates are 80-90% if treated within 72 hours and less than 50% when delayed beyond this.


Source


Rosen's Emergency Medicine: Concepts and Clinical Practice

In general, kidney stones larger than what size (mm) in diameter will not pass?

10 mm


Source

Worcester, E. and Coe, F. "Calcium Kidney Stones" N Engl J Med. Sep 2010.

True or False? Urine ouput decreases as the degree of urinary traction obstruction increases.

False.

If there is a complete obstruction, there will be no urine output. However, with partial obstructions, urine output can remain normal or actually increase.


Source

Rose, B. "Urine output in urinary tract obstruction and postobstructive diuresis" Up to Date. Nov 2004.

Grad, Y. et al. "Bitter Pills" N Engl J Med. Nov 2010.

What is considered a normal post void residual?

Less than 50 to 100 ml.


Source

Nygaard, I.  "Idiopathic Urgency Urinary Incontinence"  N Engl J Med.  Nov 2010.

What percentage of males with ischemic priapism lasting 24 hours will become impotent?

90%

Time is sexual function.


Source

Serkan, D. and Mulhall, J. "Priapism" Up to Date. 2010 Jan 28.

Tolvaptan: a new (at least to me) treatment for hyponatremia

Tolvaptan is an ADH receptor antagonist. It can be used as an alternative or possible addition to water restriction or sodium chloride administration in patients with hyponatremia. Cost for the drug generally prohibits this from being used as a first line agent.

Tolvaptan should NOT be used in hyponatremic patients who are volume depleted in whom volume repletion with saline is the primary treatment.


Source

Rose, B. "Overview of the treatment of hyponatremia" Up to Date. 16 Oct 2009.

What is one of the most sensitive physical exam findings for testicular torsion?

Loss of cremasteric reflex. Several small studies have demonstrated close to 99% sensitivity.

The reflex is normally elicited by stroking or pinching the medial thigh, causing contraction of the cremaster muscle which elevates the testis.


Source

Ringdahl, E. and Teague, L. "Testicular Torsion" American Academy of Family Physicians. 15 November 2006.

Can you name 15 causes of urinary retention?

Obstructive

(1) prostatic enlargement (benign, cancer)
(2) bladder stones, neoplasm
(3) urethral stricture, stones, foreign bodies
(4) uterine or gastrointestinal mass (cancer, fecal impaction) compresses bladder neck
(5) pelvic organ prolapse: cystocele or rectocele
(6) phimosis, paraphimosis
(7) gravid uterus

Infectious / Inflammatory

(8) prostatitis
(9) urethritis
(10) vulvovaginitis
(11) herpes simplex virus (Elsberg syndrome)

Pharmacologic

(12) anticholinergics
(13) hormonal agents: estrogen, progesterone, testosterone
(14) sympathomimetics: phenylephrine (neosynephrine), pseudoephedrine (Sudafed)
(15) nonsteroidal antiinflammatory drugs via inhibition of prostaglandin mediated destrusor muscle contraction
(16) opioid analgesics

Neurologic

(17) brain lesion: stroke, multiple sclerosis, concussion, tumor, normal pressure hydrocephalus, Parkinson's disease
(18) peripheral neuropathy: diabetes, Guillain-Barre, herpes zoster, lyme, tabes dorsalis
(19) spinal cord lesion: disk herniation, trauma, tumors, spinal stenosis, meningomyelocele, transverse myelitis


Source

Selius, B. and Subedi, R. "Urinary Retention in Adults: Diagnosis and Initial Management" American Family Physician. 1 March 2008.

Can a circumcised male still get a paraphimosis?

Yes, particularly males who are - often unknowingly - incompletely circumcised. Paraphimosis is a urologic emergency where the foreskin is irreducibly retracted over the glans penis with resultant ischemia of the foreskin or glans.

Paraphimosis

Source

Huang, C. "Problems of the Foreskin and Glans Penis" Clinical Pediatric Emergency Medicine. 2009

Image source: http://nyemergencymedicine.blogspot.com/2008/03/answer-vizd-challenge-week-of-22508.html

What is the treatment for renal infarction?

Available treatments include surgery to establish collateral circulation, intra-arterial thrombolysis, catheter embolectomy and heparin therapy.

Specific treatment is dependent on duration and degree of renal infarction and the suspected cause (embolism, 75% of cases, atherosclerosis, sickle cell anemia, vasculitis, trauma).


Source

Handbook of Diseases. 3rd ed.

Any recommendations on preventing recurrent kidney stones?

Calcium stones, particularly calcium oxalate and less often calcium phosphate, are the most common type of kidney stone, making up 80% of cases. A few dietary modifications can be instituted to decrease recurrence of calcium stones:

• Drink adequate fluids to produce at least 2 liters of urine per day. This will decrease urine solute concentration.
• Increase fruit and vegetable intake. These foods increase renal citrate excretion and decrease risk of calcium oxalate stone formation.
  
• Limit animal protein. A risk factor particularly in men for some reason.
  
• Limit sodium intake. A low sodium diet enhances sodium and calcium reabsorption in the proximal tubule.
  
• Limit dietary sucrose and fructose which increase urine calcium excretion.
  
• Limit dietary oxalate (spinach, rhubarb, peanuts, cashews, almonds).
  
• DON'T limit calcium intake as this can lead to increased oxalate absorption due to decreased binding by calcium in the intestinal lumen.

Bottom line. Drink plenty of fluids and eat a healthy diet.

Source

Preminger, G. MD. "Evaluation of the adult patient with established nephrolithiasis and treatment if stone composition is unknown." Up to Date. Oct 2008.

Curhan, G. MD. "Prevention of recurrent calcium stones in adults." Up to Date. Oct 2008.

When is hematuria more than a simple UTI?

If it's a simple UTI there should be associated dysuria, frequency and in the urinalysis, pyuria and bacteria. If not, the differential and evaluation should be broadened. Specifically, other causes of bleeding, including glomerular (red cell casts, proteinuria, dysmorphic appearance of RBCs in urine) and extraglomerular bleeding (blood clots in the urine; clots almost never occur in glomerular disease) should be pursued.

Source

Rose, Burton MD and Fletcher, Robert MD. "Evaluation of hematuria in adults." Up to Date. 17 June 2008.

What is the sensitivity of color doppler ultrasonography for detecting testicular torsion?

Sensitivity is about 86% depending on the radiologist, equipment, time of day, resident vs attending reading, etc...

This means that if you have a:

• < 30 year old male


• with acute onset of severe unilateral scrotal pain


• history of prior episodes of intermittent testicular pain that resolved spontaneously


• testicle that is painful to palpation, elevated with horizontal lie, enlarged with edema, loss of cremasteric reflex, no pain relief with elevation of scrotum

Call the consulting urologist in to evaluate the patient even if the ultrasound is negative. Ultrasound, while good, is not 100% sensitive.

Source

Rupp, Timothy MD. "Testicular Torsion." eMedicine. 13 Dec 2006. <http://www.emedicine.com>