PANCE Blueprint Genitourinary (5%)

PANCE Blueprint Genitourinary (5%)

PANCE Blueprint Genitourinary (5%)

Follow along with the NCCPA™ PANCE and PANRE Genitourinary Content Blueprint


  1. Genitourinary System Flashcards (Members Only)

  2. Genitourinary 79 Question Comprehensive Exam (Members Only)

  3. Bladder disorders (PEARLS)

    1. Stress: urine leakage due to abrupt increases in intra-abdominal pressure (eg, with coughing, sneezing, laughing, bending, or lifting)
      • Treatment: strengthen pelvic floor or surgery
      Urge: results from an overactive detrusor muscle. Increased frequency. Vaginal delivery.
      • Treatment: Oxybutynin
      Overflow: Cannot empty bladder, just leaks. High PVR
      • Treatment: Self catheterization
      Functional: mobility issue Mixed: (combo of stress and urge) most common.
    2. Overactive bladder

      Overactive bladder is a term that describes a syndrome of urinary urgency with or without incontinence, which is often accompanied by nocturia and urinary frequency
      • The terms "urgency incontinence" and "overactive bladder with incontinence" are often used interchangeably
      • Overactive bladder happens mostly in women but may occur in men
      • Aging, an enlarged prostate, and diabetes are all risk factors
      Treated in a similar manner to urgency incontinence
      • Treated with pelvic floor muscle exercises
      • If this is unsuccessful, medications include anticholinergics (oxybutynin) and TCAs (imipramine)
    3. Bladder prolapse (cystocele) is a bulge of the bladder into the vagina
      • A cystocele can result from childbirth, constipation, violent coughing, heavy lifting, or other pelvic muscle strain
      • Symptoms include feeling pressure in the pelvis and vagina, discomfort when straining, and feeling that the bladder hasn't fully emptied after urinating
      Treatment includes a flexible ring pessary to support the bladder or surgical repair with mesh augmentation. In rare cases, estrogen may also be used
  4. Congenital and acquired abnormalities (PEARLS)

    1. If still non-palpable at 6 mo. well-child exam, refer to urology/surgery for evaluation and possible orchiopexy
      • ↑ Risk in premature infants 30%
      • If not repaired risks infertility and malignancy
      • Treatment: Orchiopexy by age 1
    2. Peyronie's disease

      Peyronie disease (PD) is a disorder characterized by a buildup of hardened fibrous tissue in the corpus cavernosum, causing pain and a defective curvature of the penis, especially during erection
      • Peyronie's disease is caused by repeated penile injury, typically during sex or physical activity and genetic susceptibility
      • The presenting symptoms of PD are penile pain, induration, curvature, shortening, and/or sexual dysfunction
      • Diagnosis is usually apparent from patient history and penile examination - ultrasound, plain radiography, computed tomography, and MRI
      Treatment includes medications (vasodilators) or surgery (plaque removal) may be recommended if symptoms persist or worsen.
    3. Genitourinary trauma

      Urethral trauma
      • The classic sign is blood at the meatus
      • High-riding ballotable prostate on rectal exam; scrotal or perineal ecchymosis
      Bladder trauma
      • Blunt force bladder injuries are seen with lower abdominal trauma and in conjunction with pelvic fractures, often resulting from a MVA. They are classified as a contusion, intraperitoneal rupture, or extraperitoneal rupture
      Penile fracture
      • Pain and snapping. Penis will be s-shaped, tender, with swelling and ecchymosis
      Retrograde UrethroGram (RUG): dye in penis retrograde to the bladder and x-ray looking for extravasation of dye - should be obtained prior to placing a Foley catheter if urethral injury is suspected Treatment depends on the degree of injury
      • Surgery is considered the best treatment option for penile fracture and urethral injuries and intraperitoneal or large bladder rupture
      • Extraperitoneal bladder rupture can be treated with bladder catheter (Foley) drainage and observation
      • Following bladder contusion drainage of the bladder should result in resolution within a few days. Follow-up cystography is recommended to assess integrity of the bladder wall
    4. Vesicoureteral reflux (VUR) is a condition in which urine flows retrograde, or backward, from the bladder into the ureters/kidneys
      • In young female patients, any history that points to recurrent infection, especially cystitis or pyelonephritis, should trigger an evaluation for vesicoureteral reflux (VUR)
      • Diagnose by using VCUG and monitor by using serial ultrasonography and VCUGs
      Mild to moderate VUR often resolves spontaneously, but the more serious disease may require surgical intervention
      • Children with newly diagnosed VUR are given prophylactic antibiotics depending on their clinical course
  5. Human sexuality

    1. Infection of the bladder and is characterized by dysuria without urethral discharge. E. coli (most common)
      • Treat with Nitrofurantoin (not over age 65), Bactrim, Fosfomycin
      • Ciprofloxacin- reserved for complicated cases
      • Postcoital UTI: single-dose TMP-SMX or cephalexin may reduce frequency of UTI in sexually active women
      Lower UTI in pregnancy
      • Nitrofurantoin (Macrobid): 100 mg PO BID × 7 days
      • Cephalexin (Keflex): 500 mg PO BID × 7 days
    2. Epididymitis is characterized by dysuria, unilateral scrotal pain and swelling.
      • + Prehn's sign: relief with elevation is a classic sign
      • Urinalysis and culture, along with studies for GC and Chlamydia - will reveal pyuria and bacteriuria. Ultrasound with Doppler studies if concern for torsion
      • Men < 35 chlamydia and gonorrhea: Doxycycline 100mg PO BID for 10 days + Ceftriaxone 500 mg IM in one dose, or 1 g if the patient weighs 150 kg or greater
      • Men > 35 E.coli: Treat with Levofloxacin x 10 days
    3. Unilateral swollen testicle with erythema and shininess of the overlying skin. Orchitis is rarely seen without epididymitis unless patient has mumps.
      • 25 % are associated with MUMPS
      • Over 35: E. coli, Levofloxacin
      • Under 35:  Gonorrhea and chlamydia, Ceftriaxone + doxycycline/azithromycin
    4. Sudden onset of fever, chills, and low back pain combined with urinary frequency, urgency, and dysuria.
      • Digital rectal exam = boggy, warm, tender, and enlarged prostate
      • Urinalysis will reveal pyuria (↑ WBC in acute) +/- hematuria
      • Men < 35: chlamydia and gonorrheaceftriaxone and doxycycline
      • E coli in men > 35: treat with fluoroquinolones or Bactrim for 4-6 weeks to ensure eradication of the infection
      • Chronic prostatitis is treated with fluoroquinolones or Bactrim x 6-12 weeks
      • If you suspect acute prostatitis, do not massage the prostate. This can lead to sepsis
    5. Irritative voiding + Fever + flank Pain + nausea and vomiting + CVA tenderness
      • Organism: E. coli
      • Urinalysis: Bacteria and WBC casts
      • Outpatient: ciprofloxacin/levofloxacin +/- ceftriaxone IM
      • Inpatient: Ciprofloxacin/levofloxacin or imipenem for more severe disease
    6. In urethritis, the main symptoms are dysuria, and primarily in men, urethral discharge
      • The sexually transmitted pathogens Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and herpes simplex virus are common causes in both sexes
      • Diagnosis: nucleic acid amplification test (NAAT)
      • Sexually active patients with symptoms are usually treated presumptively for STDs pending test results
        • The preferred regimen for gonococcal infections is a single IM dose of ceftriaxone (500 mg for individuals <150 kg or 1 g for individuals ≥150 kg)
        • If testing results for C. trachomatis are not available at the time of treatment, presumptive therapy for chlamydia coinfection is also indicated. In such cases, doxycycline 100 mg twice daily for seven days
        • Consider replacing doxycycline with azithromycin 1 g PO if compliance is in question or pregnancy
        • In the event that results of microbial diagnostic testing are available prior to the patient's receipt of therapy, antimicrobial treatment can be directed toward the identified pathogen(s)
    1. Bladder cancer (Lecture)

      Painless hematuria in a smoker, transitional cell carcinoma is the most common type.
    2. Penile Cancer

      The diagnosis of penile carcinoma should be suspected in men who present with a penile mass or ulcer, particularly in those who are uncircumcised
      • The diagnosis requires biopsy for tissue confirmation
      Treatment involves surgery for all stages of penile cancer. Other options include radiation and chemotherapy
    3. Most common area: Peripheral zone. Digital Rectal Exam: hard, irregular, nodular prostate Tumor marker: PSA. (also elevated in BPH)
      • PSA is considered normal < 4
      • PSA > 4 think BPH, prostate CA and prostatitis
      Recommended age to start annual prostate screening:
      • White male average risk: 50 years old
      • Black male + Family History or + BRCA mutations: 40 years old
    4. Presents as a firm, painless, non tender testicular mass
      • Seminoma is the most common type (60%)
      • Risk factors include history of cryptorchidism
      • Diagnostic studies: Initial-Ultrasound. Tumor markers: AFP, βHCG
  6. Nephrolithiasis/urolithiasis (ReelDx + Lecture)

    Flank pain radiating to groin, hematuriaCVA tenderness.
    • Lithotripsy: Stones > 1 cm unlikely to pass. Lithotripsy is indicated in patients with stones > 6 mm in size or intractable pain.
    • Hydration:  Stones < 5 mm likely to pass.
    • Calcium oxalate (80%): Most common, excess oxalate, hyperparathyroidism, radiopaque.
    • Struvite (10%): Associated with UTI with Klebsiella and Proteus species, radiopaque.
    • Uric Acid (7%): Excess meat/alcohol, gout, radiolucent.
    • Cystine (1%): Rare genetic, radiolucent.
    1. Occurs when a man can't get or keep an erection firm enough for sexual intercourse
      • Psychological
      • Organic causes include hypertension, neurological problems from diabetes, and hormonal dysfunction
      • Medication side effects
      • Nocturnal penile tumescence used to evaluate sleep erections
      • Do not use with nitrates may cause hypotension
      • Treat with phosphodiesterase 5 inhibitors Sildenafil (Viagra), Tadalafil (Cialis), Vardenafil (Levitra)
      • Weight loss, smoking and alcohol cessation, hormone replacement and vacuum erection devices, and surgery
    2. Hypospadias/epispadias

      Epispadias is when the urethra opens onto the topside of the penile shaft
      • Diagnosis is usually made during the newborn exam but imaging studies (excretory urogram) can aid in the diagnosis
      • Treatment is surgical repair, usually performed before 1-2 years of age
      Hypospadias (more common than epispadias) is when the urethra opens onto the bottom (underside) of the penile shaft 
      • Diagnosis is usually made during the newborn exam but imaging studies (excretory urogram) can aid in the diagnosis
      • Treatment is surgical repair, usually performed before 1-2 years of age. Do not circumcise- foreskin may be used to reconstruct urethra
    3. Paraphimosis: Inability to return foreskin to normal position causes tourniquet effect, is a medical emergency
      • Entrapment of the foreskin behind glans
      • More acute than phimosis
      Phimosis: Inability to retract the foreskin, usually resolves by age 5, betamethasone topically, if no improvement circumcision
      • Unable to retract foreskin
      • More chronic than paraphimosis
  7. Prostate disorders (PEARLS)

    1. Enlargement of transitional zone - In men with BPH, avoid use of anticholinergic and antihistamines
      • PSA is often elevated - considered normal < 4
      • PSA > 4 think BPH, prostate CA and prostatitis
      • Symptomatic: Alpha blocker (Tamsulosin)
      • Decrease prostate size: 5 alpha reductase inhibitors (Finasteride)
      • Definitive: TURP
  8. Testicular disorders (PEARLS)

    1. Hydrocele: On physical exam mass will transilluminate Varicocele: Dilation of the pampiniform plexus
      • Bag of worms in scrotum (made worse when patient is upright and improves when patient is supine)
      • More common on left
    2. Asymmetric high riding testicle bell clapper deformity”, negative prehn's sign (lifting of testicle will not relieve pain). Teenage males.
      • Very tender to palpation. Cremaster reflex absent.
      • Blue dot sign: Tender nodule 2 to 3 mm in diameter on the upper pole of the testicle.
      • Diagnosis: Radionuclide study and ultrasound
      • Surgical emergency: Repair both testes within 4-6 hours
    1. Urethral Prolapse

      Urethral Prolapse Circumferential protrusion of the distal urethra through the external urethral meatus. It is a rarely diagnosed condition that occurs most commonly in prepubertal girls and postmenopausal women
      • Vaginal bleeding is the most common presenting symptom of urethral prolapse
      • Upon examination, round, often doughnut-shaped protrusion mucosa is observed obscuring the urethral opening
      Treatment includes topical estrogen creams, vaseline, and sitz baths
      • Surgical excision is justified in young patients with symptomatic urethral prolapse or with recurrent urethral prolapse
    2. Urethral Stricture

      Urethral Stricture Narrowing of the urethra caused by injury, instrumentation (TURP), infection (typically with Gonorrhea) and certain non-infectious forms of urethritis
      • A urethral stricture should be suspected in men with chronic obstructive voiding symptoms, especially if noninvasive studies (eg, uroflowmetry, ultrasound postvoid residual measurement) demonstrate poor bladder emptying with a low peak rate of urine flow
      Treatments include urethral dilation or stent placement
      • An open urethroplasty is an option for longer, more severe strictures


The Daily PANCE and PANRE

Get 60 days of PANCE and PANRE Multiple Choice Board Review Questions delivered daily to your inbox. It's 100% FREE and 100% Awesome!

You have Successfully Subscribed!