GU/Focal Problems for Urology Small Groups

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Case 1

You are the Clinical Clerk in ER and are asked to see Paul, a 30 year old man, who was awakened from sleep 2 hours ago by severe left sided back and flank pain which radiates into his left lower quadrant. He has never experienced such a pain before. His general health has been good and he has no intercurrent medical problems. On examination, he is in evident distress and is pale and sweating. His vitals include:

BP - 110/64
Pulse - 100/min
Temperature - 37.2°C

He is exquisitely tender on palpation of the left flank and is also uncomfortable in the left lower quadrant. There is no rebound tenderness. Bowel sounds are normal.

Laboratory investigations include:

Hgb - 138 g/l
WBC - 7,200
Urinalysis:
  WBC - 2-4/hpf
  RBC - >100/hpf
  Casts - 0
  Bacteria - 0
  1. Outline a brief differential diagnosis for Paul's presentation.
    • Small ureteral stones:
      • Flank pain with radiation into lower quadrant, testis, penis or labia.
      • Small ureteral stones frequently present with severe pain (renal colic) while large or staghorn calculi may present with dull ache or flank discomfort.
      • > 90% of patients will have microscopic or gross haematuria.
  2. What will be your immediate management steps?
    • The initial management of a stone is designed to relieve pain, treat co-existing infection and relieve obstruction to preserve renal function.
    • In many instances treatment is expectant with high fluid intake/IV fluids, analgesics and antibiotics as required.
  3. What further investigations will you order?
    • For definitive diagnosis an IVP is required which shows the level and degree of obstruction and identifies radiolucent stones as 'filling defects'.
    • Renal ultrasound
  4. What treatment options will be most likely to deal effectively with Paul's problem?
    • After the size is determined, the chances are it will be left to pass on its own.
    • Extracorporeal shock wave lithotripsy

Case 2

Laura is a 53 year-old woman who presents with complaints of fatigue, a 4 kg weight loss and general malaise. She also describes right upper quadrant and back pain and early satiety with meals. She has previously been in good health and relates no significant medical or surgical history. She specifically denies any genitourinary symptoms. Her BP is 128/74. Abdominal examination reveals a non-tender mass in the right flank. Pelvic and rectal examinations are negative.

Laboratory investigations include:

Hgb - 140g/l
WBC - 10 200
Urinalysis:
  WBC - 2-4/hpf
  RBC - 0-1/hpf
  bacteria - 0
  1. List a brief differential diagnosis for this woman's complaints.
  2. What initial investigations will you consider for Laura?
    • Renal ultrasound
    • CT or IVP
  3. Based on the results presented in the Small Group Session, how will you investigate her further?
  4. From the findings of the investigations presented in the Small Group Session, what management options are appropriate to offer to Laura?

Case 3

Jenna is a 10 year-old girl referred because of recurrent UTIs. Over the past 2 years, she has had several episodes of frequency, urgency and pain with voiding. These symptoms have resolved with short courses of antibiotic prescribed through walk-in clinics. Her voiding is otherwise normal and she was "potty trained" at 21 months.

Jenna is otherwise in good health. Her mom recalls that she frequently complains of "tummy aches" and volunteers that JL seems less energetic than her brothers and sister. On examination, Jenna seems small for her age but there are no other positive findings except for some irritation and redness around the introitus.

Recent laboratory investigations include:

Hgb - 118g/l
WBC - 11,200
Urinalysis:
  WBC - 20-25/hpf
  RBC - 2-4/hpf
  bacteria - many
Urine C&S:
  >100,000 colonies of E coli sensitive to all antibiotics tested
  1. From Jenna's presentation, what is your differential diagnosis of her problem?
  2. What will you recommend for her initial management?
  3. What further investigations will you order?
  4. What will you suggest for her long term management?

Case 4

Charles is 62 years of age. He has become increasingly bothered by symptoms of voiding dysfunction, including nocturia x 3, daytime frequency, a poor stream and a sense of incomplete bladder emptying. He has experienced no dysuria, hematuria or incontinence. General physical examination is unremarkable. DRE demonstrates no anal or rectal pathology. The prostate is moderately enlarged, non-tender, smooth and regular.

  1. What are the 3 most likely causes for Charles' symptoms?
  2. What, if any, further investigations will you perform?
  3. If Charles' PSA is 1.2 μg/l, what form of management are you most likely to recommend?
  4. If Charles' PSA is 7.2 μg/l, how will this change your management plan?
  5. What will you do if his PSA is returned at 4.1 μg/l?

Case 5

Bill is a 19 year-old college student. He presents because of a left scrotal swelling, which he first noticed 4 months ago. He states that "it feels as if I've grown a third testicle". He does not describe pain or discomfort except when he's wearing tight jeans. He has never had a UTI or STD and denies any trauma.

  1. List your differential diagnosis of Bill's scrotal swelling.
  2. Outline the steps you will take in the physical examination of his scrotum.
  3. What further investigations may help to establish a firm diagnosis?
  4. If this mass is found to be a varicocele, how will you counsel Bill about this condition and what treatment options will you offer to him?

Case 6

Gayle is a 52 year-old married factory worker. You are asked to see her in the ER because of a presenting complaint of hematuria. She says that, since awakening this morning, she has passed grossly bloody urine x3. For the past couple of days she thinks she has been voiding a bit more frequently but has had no urgency or pain with voiding. She has had occasional lower UTIs in the past but has never had bleeding. Her past history is significant only for radiation therapy of cancer of the cervix 11 years ago. She has been discharged from follow up at the local cancer clinic.

On examination, her vitals include:

BP - 162/84
Pulse - 82/min

Abdominal examination is unremarkable except for some mild suprapubic tenderness.

Initial laboratory investigations include:

Hgb - 121g/l
WBC - 9000
Creatinine - 80 μmol/l
Urinalysis:
  Grossly bloody
  1. What is you differential diagnosis for Gayle's presenting complaint?
  2. What other information do you want to know from Gayle's history and physical exam?
  3. How will you organize your further investigation of Gayle's bleeding?
  4. From the information given to you in the Small Group Session about Gayle's diagnosis, what is her prognosis and what follow up will you recommend?