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Urology 2


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What separates the prostate posteriorly from the rectum?
2 layers of Denonvilliers' fascia
What is Denonvilliers' fascia remnants of?
Serosal rudiments of pouch of Douglas
What is the bloodless plane demarcated by the posterior segment of the renal artery?
Brodel's line
What forms the ejaculatory ducts and where do these enter the urethra?
Seminal vesicles and vas deferens --> veru montanum in the prostatic urethra
What are the layers of the penis (from outside in)?
Skin, Colles' Fascia, Buck's Fascia, Tunica albuginea (around the corpora cavernosa)
Lowsley Classification of prostate anatomy
5 lobes: anterior, posterior, median, right lateral and left lateral
McNeal Classification of prostate anatomy
Peripheral zone, central zone, transitional zone, anterior segment, and preprostatic sphincteric zone
Which glands lie just beneath the transitional epithelium of prostatic urethra?
Periurethral glands
Arterial supply to the prostate
Inferior vesical arteries, middle rectal arteries, internal pudendal
What is the main chain of lymph nodes into which the prostate empties?
Obturator nodes
What does the spermatic cord contain?
1. Vas deferens
2. Genital branch of the genitofemoral nerve
3. Pampiniform plexus
4. Artery of the vas
5. Internal and external spermatic arteries
6. Lymph vessels
7. A few fibers of the cremaster muscle
What fasical layer separates the testis from the scrotal wall?
Parietal tunica vaginalis
2 types of cells in the seminiferous tubules?
Supporting (Sertoli) cells and spermatogenic cells
Blood supply to the testes is closely associated with blood supply to what other organ?
kidneys b/o common embryologic origin
What structure encloses the urethra in the male?
Corpus spongiosum
Each corpus cavernosum is surrounded by ____ which is then enclosed by ____
1. Tunica albuginea
2. Buck's fascia
From where does the suspensory ligament of the penis arise?

Where does it insert?
1. Arises from Linea alba & Pubic symphysis
2. Inserts into fascial covering of corpora cavernosa
What glands are located in the submucosa of the male urethra?
Glands of Littre
Arterial supply of penis and urethra?
Internal pudendal artery (dividing into deep artery of the penis (supplies CC), dorsal artery of penis,and bulbourethral artery)
Where do the superficial dorsal vein and deep dorsal vein lie in relation to Buck's fascia?
Superficial lies external; deep lies beneath
What are the names of the periurethral glands, opening on the floor of the female urethra just inside the meatus?
Glands of Skene
Four different phases in kidney CT and timing
1. Angiographic phase (15-40s after contrast injection)
2. Cortical phase (25-80s) (greatest corticomedullary contrast at this time)
3. Nephrogenic phase- (90-120s) (entire renal parenchyma homogeneous)
4. Excretory or urographic phase (3-5min)
Stone protocol consists of...
Non-contrast spiral CT
Why no contrast for stone protocol?
It leads to difficulties in defining bowel diverticula and distinguishing appendix from calculi
Protocol for evaluating renal masses...
CT without, then with IV contrast
If a renal mass is indeed detected after CT, what is the next radiographic study to be ordered?
Chest CT
What is the protocol for evaluating renal infection?
CT without contrast (if questions still remain, use IV contrast next)
Name the 9 steps in an IV urogram (IVU) - aka IVP or excretory urogram
1. Scout abdomen & tomogram (KUB to check for excess bowel gas and other benign objects)
2. Inject contrast IV bolus
3. Tomograms at consecutive levels through middle of kidney at 1, 2, and 3 min after injection
4. 5-minute abdominal radiograph
5. Placement of abdominal compression
6. 10-minute coned views of the kidney, AP and both 30 degree posterior obliques
7. Abdominal film after compression device released ("release film")
8. AP and oblique views of the bladder
9. Postvoid AP bladder
Why is a compression device used in an IVU?
It causes partial obstruction of the ureters, to improve visualization of intrarenal collecting system and ureters
When during an IVU is the best time to visualize the ureters?
At the release film
Current indications for IVU include:
1. Evaluation of calyces and ureters
2. Detailed eval of calyces, UPJ, and UVJ
In Peyronie's disease, where is the most common location of the fibrotic scar?
Within the tunica albuginea of corpora cavernosa- dorsal aspect
At what age should DREs begin to be performed?
40yo (or any male presenting for urologic evaluation)
What is suggested by the presence of a soft, cystic mass palpable in the midline near the base of the prostate?
Presence of a mullerian duct cysts or enlarged utricle (remants of the female mullerian system)
An enlarged utricle is occasionally seen in patients with what other congenital abnormality?
Proximal hypospadias
What physical exam maneuvers should be attempted with a varicocele?
1. Valsalva (should increase the size)
2. Supine (should reduce)
On what side is a varicocele usually detected?
One French = __ mm
How is rigid cystoscopes better than flexible?
Rigid provide a greater field of vision and allows more therapeutic options
Normal pH of urine is between
5 and 8
What is the normal value of creatinine clearance?
90-110 mL/min
What abnormality may be seen on CBC in patients with renal insufficiency and why?
Anemia b/o decreased production of EPO
3 main risks of IV contrast material?
1. Allergic reaction
2. Renal toxicity
3. Local tissue reaction (if IV needle infiltrates at time of injection)
How should a patient be prepared for urography?
Administer clear liquids beginning the evening before the study and NPO 6h before study
What drug should NOT be given when a diabetic is given IV contrast?
Metformin (stop 24h before and wait 24h after to restart)
5 steps in usual film sequence for urography?
1. Plain film (KUB)
2. 1 minute (visualizes renal parenchyma)
3. 5 minutes (early visualization of upper collecting system)
4. Tomograms (renal outlines)
5. 15/20 minutes (late visualization for lower ureters and bladder)
IVU showing a tear-drop shaped bladder suggests...
Pelvic lipomatosis
IVU showing a Christmas-tree shaped bladder suggests...
Neurogenic bladder
3 indications for renal venography
1. Evaluate tumor thrombus (RCC)
2. Definitive eval of renal vein thrombosis
3. Renal vein renin determination in renovascular HTN
2 main indications for angiographic renal embolization
1. RCC (to facilitate operative management of large tumors with venal caval thrombi)
2. Control hemorrhage from perc bx, AVM, or primary/met tumor
How does a renal cyst appear on ultrasound?
Homogeneously hypoechoic with very thin walls
Who is most often associated with ureteroceles?
Girls with duplicated collecting systems who present with UTIs
What does a ureterocele appear as on U/S? What is the name of this?
A thin but clearlyl defined membrane (called Chawala's membrane)
How can one use U/S to confirm varicocele?
Use doppler while patient performs valsalva (and it will demonstrate retrograde flow into the testicle)
What is the typical TRUS findings for CaP?
Hypoechoic area within peripheral zone
What is the PSAD and how is it used?
It is the PSA density (serum PSA divided by the prostate volume measured by TRUS). A value >= 0.15, suggests CaP
What is a Hounsfield unit of -1000, 0 and +1000
-1000 is lung (air)
0 is soft tissue
+1000 is bone
What are the 3 most important contributions of CT to urology?
1. Assessment of renal masses
2. Renal trauma evaluation
3. Nephrolithiasis
What is T1 MRI best for?
Defining anatomy
What is T2 MRI best for?
Demonstrating pathology (e.g. differentiating renal cysts from solid tumors)
How will a renal cyst and tumor appear differently on a T2 MRI?
The cyst will be very bright (tumor only somewhat bright)
What are the 3 radiopharmaceuticals based on technetium 99 and how are each handled by the kidney?
1. Tc99-DTPA (80% glomerular filtration, 20% tubular secretion)
2. Tc99- MAG3 (90% tubular secretion)- so high rate of extraction
3. Tc99-glucoheptonate (combo filtration and secretion)
On a renogram, what is the normal time delay between peak aortic flow and renal flow?
<6 seconds
3 phases of a renogram?
1. Renal blood flow
2. Parenchymal function
3. Excretion
On a renogram, what is the normal time that peak uptake should occur in renal parenchyma?
Within 5 minutes after injection
A normal DTPA renogram will demonstrate 50% emptying of nuclide from the kidney within how much time?
20 minutes
How may scintigraphy be used to diagnose AIN?
Gallium 67 is useful and will show uptake persisting greater than the normal 72 hours
Name 3 agents used to image infectious or inflammatory processes within the kidney.
1. WBC labeled with In111
2. Gallium 67
3. Tc99-DMSA
What is a lasix renal scan used for?
Differentiating between obstructive and nonobstructive hydronephrosis
What is a "normal" lasix scan?
50% emptying of the kidney and pelvis within 20 minutes after injection
How is radionuclide cystography helpful for VUR?
A VCUG should be the initial test but subsequent tests should be used with RNC b/c it has 1/1000 of the radiation exposure as VCUG
What nerves innervate the penis and are responsible for tumescence and detumescence?
Cavernous nerves
What structures do the cavernous nerves innervate that are most responsible for erections?
1. Helicine arteries
2. Trabecular smooth muscle
What are the 3 main types of erections?
1. Genital-stimulated (contact or reflexogenic)
2. Central-stimulated (noncontact or psychogenic)
3. Central-originated (nocturnal)
At what stage of sleep do nocturnal erections occur?
Why do nocturnal erections occur during REM?
Cholinergic neurons in lateral pontine tegmentum are activated while the serotonergic neurons in the midbrain raphe are silent.
What is the main arterial supply to the penis- and what are its 3 branches?
Internal pudendal arteries:
1. Cavernous artery
2. Dorsal artery
3. Bulbourethral artery
What does the cavernous artery supply?
Corpora cavernosa
What does the dorsal artery of the penis supply?
The skin, subcutaneous tissue and glans penis
What does the bulbourethral artery supply?
Corpus spongiosum
Describe the mechanics of an erection.
1. Activated autonomic nerves produce a full erection via filling and trapping of blood into the cavernous bodies
2. Ischiocavernous muscle then contracts to compress the proximal corpora and raise corpora pressure well above systolic pressure
Where do the emissary veins lie in the penis and why is this imortant?
Directly underneath the tunica albuginea (so that increased arterial pressure will increase blood in the sinusoids and therefore compress the emissary veins between the sinusoids against the tunica)
Is androgen absolutely necessary for erection?
No-- it enhances it a lot though
Do hypogonadal men show a decrease in nocturnal erections?
What is the principal neurotransmitter for penile erection and from what nerve terminals does it come from?
NO from parasympathetic NANC nerve terminals
Describe the signal transduction which occurs in penile erection.
1. During sexual stimulation, NO is released from nerve ending
2. NO diffuses into arterial smooth muscle cells and activates cGMP
3. cGMP activates protein kinase G which phosphorylates K and Ca channels resulting in hyperpolarization and SM relaxation
4. cAMP also does a similar thing
5. Phosphodiesterase (mainly type V) then breaks down cGMP and cAMP to GMP and AMP.
Name 3 conditions in which peripheral neuropathy may result in ED.
1. DM
2. Alcohol abuse (chronic)
3. Vitamin deficiency (B12)
Name 5 endocrine disorders which may result in decreased libido and ED.
1. Hyogonadism
2. Hyperthyroidism
3. Hypothyroidism
4. Addison's Disease
5. Cushing syndrome
What are the 2 classifications of arterial disease leading to ED?
1. Extrapenile (amenable to surgical repair)
2. Intrapenile
Name 3 causes of intrapenile arterial disease.
1. Aging
2. Arteriosclerosis
3. DM
Name 5 types of cavernous (venous) impotence.
1. Type 1: large veins exiting cc (congenital)
2. Type 2: venous channels enlarged due to distortion of tunica albuginea (Peyronie's)
3. Type 3: cavernous SM unable to relax b/o fibrosis, degeneration, or dysfunction of gap junctions
4. Type 4: inadequate neurotransmitter release
5. Type 5: abnormal communication b/w cc and spongiosum or glans (trauma, congenital or consequent to shunt procedure for priapism)
What are 3 main classes of drugs listed as causes of ED?
1. Antipsychotics
2. Antidepressants
3. Centrally acting anti-hypertensives
With regard to ED, what do alpha-adrenergic antagonists do?
May cause retrograde ejaculation due to relaxation of the bladder neck
How do beta-blockers cause ED?
They potentiate alpha1 adrenergic activity
What diuretics cause ED?
Spironolactone and thiazides (mechanism unknown)
How does alcohol affect ED?
In small amounts, it improves it and increases libido (b/o vasodilatory effects). In large amounts, it causes central sedation, decreased libido and transient ED
ED severity is classified into how many categories? What's the name of the self-reporting measure?
5 (severe, moderate, mild to moderate, mild and no ED)

International Index of Erection Function (IIEF)
The average man has how many episodes of NPT per night and how long should each last?
3-5 per night, each lasting 30-60 minutes
Name 5 neurologic tests for ED.
1. Biothesiometry
2. Bulbocavernosus reflex latency
3. Genitocerebral evoked potential
4. Smooth muscle EMG
5. Tests for penile vascular function
What is CIS and what does it detect?
Combined intracavernous injection and stimulation test- it detects vascular status of penis
What is a normal CIS result?
A rigid erection lasting for more than 20 minutes (indicates normal venous function)
What is used to inject in the CIS test?
1. Alprostadil
2. Phentolamine and papaverine
Name 5 methods of evaluating penile vascular function.
1. CIS
2. Duplex US
3. Cavernous arterial occlusion pressure
4. Cavernosometry and cavernosography
5. Arteriography
What are two lifestyle changes that may be attempted with ED?
1. Better diet & exercise
2. No long-term bicycling or sitting
What antidepressants are preferred for those with ED?
Trazodone & buproprion
What is the most common laboratory abnormality in men being treated with testosterone?
What surveillance labs should be ordered for a patient on testosterone therapy?
1. LFTs
2. H&H
3. Cholesterol & lipid profile
How does papaverine injection therapy work?
It inhibits PDE leading to increased cAMP and cGMP
2 major disadvantages of papaverine injections are...
1. Corporal fibrosis (1-33%) due to low acidity
2. Occasional LFTs
What is the mechanism of phentolamine injection therapy?
Competitive alpha-adrenergic antagonist (= affinity for alpha 1 and alpha 2)
3 types of intracavernous injection therapy?
1. Papaverine
2. Phentolamine
3. Alprostadil (PGE1)
What is the best regimen for treating priapism due to injection therapy?
Intracavernous injection of diluted phenylephrine 250-500ug q3-5 minutes until detumescence
In what 3 patients is intracavernous injection contraindicated?
1. Sickle cell
2. Schizophrenia or severe psychiatric disorder
3. Severe venous incompetence
What is the most commonly used technique for penile revascularization?
Bypass from inferior epigastric artery to dorsal artery or deep dorsal vein of penis
What are 3 types of penile prostheses?
1. Malleable (semirigid)
2. Mechanical
3. Inflatable (2 and 3 piece)
Which penile prostheses last longer than others?
Malleable last longer than inflatable
What are potential complications of IPP?
1. Mechanical failures
2. Cylinder leaks
3. Tubing leaks
4. Infection
5. Perforation
6. Persistent pain
7. Autoinflation
What is the 5-year failure rate of IPP?
How long do penile prostheses generally last?
10-15 years (and then will need a replacement)
What is the mechanism of retrograde ejaculation?
Dysfunction of the internal sphincter or the bladder neck
In what 3 states/conditions does retrograde ejaculation occur?
1. After prostatectomy
2. Alpha-blocker therapy
3. Autonomic neuropathy (DM)
What is used to treat retrograde ejaculation?
Alpha sympathomimetics (or eliminate the alpha blocker therapy)
What are 4 things which can be used to treat premature ejaculation?
1. Desensitization
2. The Squeeze technique
3. Application of local anesthetic or condom
4. SSRIs
What is the treatment of choice for renal AV fistulas?
Transcatheter embolization
Optimal time delay between embolization and nephrectomy for RCC is...
1 day
What is post-embolization syndrome?
Pain, n/v, fever, leukocytosis following tumor embolization (very common & should not delay surgery!)
What material is used for renal tumor embolization?
What approach is preferred for embolization of varicocele?
IJV to the L gonadal vein
Recurrence rate for embolization of varicocele?
What are 7 indications for treatment of renal artery aneurysms?
1. Interval enlargement
2. Diameter >2.5cm
3. Lesions in women of child-bearing age
4. Pain
5. Hematuria
6. Renovascular HTN
7. Intrarenal thromboemboli
What is the usual anatomic relationship between the renal artery and vein?
Artery is posterior to the vein
With a R-sided nephrectomy, what plane is crossed to direct one from the IVC to the R renal vein?
Plane of Leriche
Where is the most likely location of a urethral stricture after straddle injury?
Bulbar urethral injury
Patients with what disorder should you be wary of latex allergy?
What is a good alternative for a urethral catheter in those with latex allergy?
What element forms the basis of MRI?
How do blood vessels appear on MRI?
How does calcium appear on MRI?
What is Technetium 99c's half life?
6 hours
What radionuclide agent is best used for renal vascular imaging?
What radionuclide agents may be used in patients with renal failure?
123-I and 131-I hippurate (b/c renal concentration may occur with as little as 3% of normal renal function)
What is a "superscan"?
When the kidneys can't be imaged b/c the bone (from prostatic boney mets) has intensely uptaken the radionuclide
How many Hounsfield units would be typical of a renal cyst on noncontrast CT?
What is a renal pseudotumor?
An area of normal renal parenchyma that gives the appearance of a solid renal mass
What % of RCCs are avascular?
Is routine biopsy of solid renal masses recommended? Why or why not?
NO- because of the high incidence of false negative findings in patients with RCC
In a newborn, what is the #1 and #2 most common causes of an abdominal mass?
1. Hydronephrosis (usually secondary to UPJ obstruction)
2. Multicystic kidney
What is the most common malignancy of the newborn?
Neuroblastoma (50% of all neonatal malignant tumors)
In a neonate, what is the most common cause of hydronephrosis?
UPJ obstruction
If US shows hydronephrosis in a child, what is the next study that should be ordered?
At what age is neuroblastoma and Wilms's tumors most common?
Neuroblastoma: <2yo
Wilms' Tumor: >2yo
What is aniridia and what is it associated with?
Developmental absence of most of the iris-- associated with Wilms tumor
What urologic abnormality is microcephaly associated with?
PUVs and Beckwith-Wiedemann syndrome
Macroglossia should make you think of......
Hemihypertrophy should make you think of...
Webbing of the neck should make you think of what syndrome (and what associated renal abnormality)?
Turner's Syndrome & horseshoe kidney
What is the significance of bright pink or bluish subcutaneous nodules in the newborn?
May indicate the presence of disseminated neuroblastoma
What is the significance of HTN in a child with an abdominal mass?
It may suggest the presence of neuroblastoma, congenital mesoblastic nephroma, and less commonly Wilms tumor, hydronephrosis or multicystic kidney
What is the significance of hematuria in a newborn with an abdominal mass?
Renal vein thrombosis
Offspring of which mothers are at increased risk for renal vein thrombosis?
Diabetic moms
What is the most likely diagnosis of an abdominal mass in a female neonate with a bulging interlabial mass?
Hydrocolpos secondary to imperforate hymen
What is the significance of stippled calcification in a retroperitoneal solid mass?
50% of patients with neuroblastoma have stippled calcification
Which tumor is more likely to be fixed rather than mobile- neuroblastoma or Wilms?
What are the 2 primary causes of masses arising from the female genital system?
1. Hydrocolpos
2. Ovarian cysts
How often are the kidneys palpable in the neonate
Very often
What is the usual age for urinary TB?
Young adults (60% between 20-40)
What are the primary sites of TB infection in the GU system?
Kidneys & possibly the prostate
What is the route of infection for GU TB?
Descending from the kidney
Chronic draining scrotal sinus should make you think of...
TB of the GU tract
How is GU TB diagnosed?
Demonstration of tubercle bacilli in urine by culture
What are the usual earliest symptoms of renal TB?
Vesicular sx including burning, frequency and urgency
A thickened and beaded vas deferens suggests...
What is the "great mimicer" of GU TB?
Schistosomiasis (b/c both present with sx of cystitis and some hematuria)
Is surgery necessary for GU TB?
Not usually... medical treatment with 3-drug protocol is appropriate
Who does abacterial cystitis usually affect?
Usually adult men
What is the suspected etiology of abacterial cystitis?
Mycoplasmas and chlamydiae. Possibly adenovirus
How are the initial presentations of renal TB and abacterial cystitis different?
Renal TB comes on gradually while abacterial cystitis is sudden onset. Also, renal TB will reveal deep chronic ulcers while the ulcers of abacterial cystitis are superficial.
Name 4 drugs used to treat abacterial cystitis.
1. Tetracyclines
2. Chloramphenicol
3. Streptomycin
4. Neoarsphenamine (it's an arsenical- drug of choice but hard to find)
How is vesical candidiasis treated?
Alkalinize urine with sodium bicarb for urine pH of 7.5. If this fails, amphotericin B instilled into bladder.
Yellow bodies called "sulfur granules" are pathognomonic for what infection?
Actinomyces israelii
What is the drug of choice for infection with actinomyces?
Penicillin G for 4-6 weeks followed by Penicillin V for prolonged period
Name 3 drugs to be used for treatment of actinomyces
1. Penicillin G (choice drug)
2. Sulfonamide
3. Streptomycin
Name 3 types of schistosomiasis... and corresponding locations.
1. Schistosoma mansoni (central America, Pakistan, India)
2. Schistosoma japonicum (middle east)
3. Schistosoma haematobium (Africa, Saudi Arabia, Israel, jordan, Lebanon, Syria)
Which schistosoma type primarily affects the bladder? What do the other schistosoma types affect?
Haematobium affects the bladder. Mansoni and japonicum primarily affect the colon.
Where does the adult S. haematobium worm live?
In the prostatovesical plexus of veins
Main symptom of schistosomiasis?
What are the 3 drugs of choice for treating schistosomiasis?
1. Praziquantel (for any schisto) x 1 day
2. Metrifonate (only for haematobium) 3 total doses (1 dose q2wk)
3. Oxamniquine (only for mansoni)
What nematode is responsible for filariasis?
Wuchereria bancrofti
What is the usual host to deliver filariasis?
Most common symptoms associated with filariasis?
1. Lymphadenitis and lymphangitis
2. Inflammation of epididymis, testis, scrotum, and spermatic cord
What are the 2 key lab findings in filariasis?
1. Chylous urine (top layer fatty, middle layer pinkish, bottom layer clear)
2. Eosinophilia
What is the treatment of choice for filariasis?
Diethylcarbamazine (hertrazan) but it is very toxic and only kills microfilariae (and not adult worms)
How does GU echinococcus usually occur?
After rupture of an echinococcal liver cyst
What cystic findings would suggest an echinococcal cause?
Calcifications along the rim
What is the treatment of choice for renal hydatid (echinococcus) disease?
What sex usually does NOT have symptoms related to urethritis?
WOMEN (men usually will have discharge)
Gram-negative intracellular diplococci...
N. gonorrhea
Are urethral infections identified after treatment usually reinfections or treatment failures?
Name 4 symptoms of disseminated gonococcal infection.
1. Petechial or pustular skin lesions
2. Asymmetrical arthralgias
3. Septic arthritis
4. Tenosynovitis
Recommended treatment for NGU (choice and alternatives)?
Choice: doxy or azithromycin
Alternative: 7 days of EES or ofloxacin
What testing should be done if epididymitis is associated with UTIs?
Evaluation of GU anatomic abnormalities
What finding is usually associated with epididymitis?
What is the organism associated with chancroid?
Haemophilus ducreyi
In penicillin-allergic patients, what is the treatment of syphilis?
2 week course of Doxycycline or tetracycline
Main signs of chancroid?
Painful genital ulcer and the Bubo! (inguinal adenopathy)
Treatment of chancroid?
1. Azithromycin x 1
2. Ceftriaxone x 1
3. Ciprofloxacin x 3 days
4. Erythromycin base x 7 days
Treatment of granuloma inguinale?
1. TMP/SMX BID x 3 weeks
2. Doxy BID x 3 weeks
Treatment of lymphogranuloma venereum?
Doxy BID x 3 weeks
Causative organism of lymphogranuloma venereum is...
C. trachomatis (serotypes L1, L2, and L3)
Clinical presentation of lymphogranuloma venereum?
Tender inguinal or femoral LAD
What is the causative organism of granuloma inguinale?
Calymmatobacterium granulomatis (GN intracellular bacillus)
Granuloma inguinale aka...
Clinical presentation of granuloma inguinale?
Painless beefy red progressive genital ulcers; usually NO LAD
What are some topical treatments for HPV warts?
1. Podophyllin
2. Imiquimod
3. Trichloracetic acid
4. Cryotherapy
Which HIV type causes most HIV infections?
What are Bougie a boules used for?
To determine urethral and meatal size (sized from 8F to 40F)
In children, what is the usual size French for catheters?
Bladder tumor may be fulgurated endoscopically with what device?
Bugbee electrode
Electrosurgical units provide two types of current:
1. High frequency (for cutting and vaporization of tissue)
2. Low frequency (for heating tissue and producing coagulation)
What is the usual irrigating fluid used in transurethral surgery?
3% sorbitol
Name 6 complications of transurethral surgery.
1. Incontinence (usually resolves within 6 weeks)
2. Impotence
3. Retrograde ejaculation
4. Bleeding
5. Epidiymoorchitis
6. Urethral stricture and bladder neck contracture
What is the classic triad of acute adrenal insufficiency?
1. Hyponatremia
2. Hyperkalemia
3. Hypotension
What are the 4 principal types of congenital adrenal hyperplasia? Which is the most common?
1. 21-hydroxylase deficiency (most common: >90%)
2. 11beta-hydroxylase deficiency
3. 17alpha-hydroxylase deficiency
4. 3beta-hydroxydehydrogenase deficiency
Which type of CAH is the only life-threatening one?
21-OH deficiency
How is CAH diagnosed?
Elevated 17-hydroxyprogesterone in plasma (or its metabolite pregnanetriol in urine)
How is CAH treated?
Prednisone (or hydrocortisone in infants)
What history should be asked in the case of acute urinary retention?
Any cold remedies containing nasal decongestants and antihistaminic compounds (anti-cholinergic properties)
50% of testicular torsion cases occur at what time of day?
During sleep
What are the 2 general types of testicular torsion?
1. Extravaginal (in neonates)
2. Intravaginal (associated bell-clapper deformity)
What is the "bell-clapper" deformity?
A congenital high investment of the tunica vaginalis on the spermatic cord, allowing the testis to rotate on the cord
Which way do the testes usually rotate in torsion?
Always TOWARD the inner thigh
What is Prehn's Sign?
Elevating the testicle will decrease pain in epidiymoorchitis (+ Prehn's) and will increase pain in torsion (- Prehn's)
Where does Fournier's gangrene begin and where does it spread?
It begins in the scrotum or penis and spreads along fascial planes (beneath Scarpa's fascia) to the perineum and abdominal wall up to the axilla
What are the 3 usual sources of Fournier's gangrene?
1. GU (50%)
2. Colorectal (33%)
3. Cutaneous (20%)
What is phimosis and how is it treated?
Inability to retract the foreskin over the glans. Treat with dorsal slit or circumcision
What is paraphimosis and how is it treated?
Condition in which foreskin becomes trapped in a retracted position behind the glans. Treat with firm compression of the glans with continuous traction of the foreskin and anesthesetics (lidocaine).

**SCHEDULE CIRCUMCISION 3-4 days afterwards (after inflammation and edema have subsided)
Name 7 drugs associated with priapism.
1. Trazodone
2. Intracavernosal injection
3. Alcohol
4. Marijuana
5. Thorazine
6. Antihypertensives
7. Heparin
What are some infiltrative causes of priapism?
Leukemia, lymphoma, bladder or prostate carcinoma
Name 3 miscellaneous causes of priapism.
1. Trauma
2. TPN
3. Dialysis
Two types of priapism include:
1. Low flow (ischemic or venoocclusive)
2. High flow (nonischemic or arterial)
How long should an erection last for it to be considered priapism?
>4 hours
What is used to treat priapism in sickle cell disease patients?
1. Hydration
2. Alkalinization
3. Transfusion
4. Viagra
How is priapism treated medically?
Irrigation with NS and aspiration. If this fails, then intracorporal injection of phenylephrine (alpha agonist)
What anesthetic should be used to treat priapism?
Ketamine (achieves detumescence in 50% of cases)
What surgical procedure may be used to treat prolonged priapism?
Surgical shunting of corpora cavernosa by creation of fistula b/w glans penis and corpora cavernosa
What is the Winter procedure?
Surgical shunting for priapism with creation of fistula between glans penis and corpora spongiosum
What sx occur with autonomic dysreflexia?
1. Dangerous systolic HTN
2. Sweating
3. Paradoxic bradycardia
What patients are prone to autonomic dysreflexia?
Patients with spinal cord injury above T6, viable distal cord and intact sympathetic outflow.
What are the GU causes of autonomic dysreflexia?
Usually occurs b/o overdistended bladder, urinary infection or stones.
Where do the deep dorsal veins of the penis empty?
Santorini's vesicoprostatic plexus

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