NMS Q&A Family Medicine

Problems of the Urinary Tract 11110. The answer is A. The anterior urethra of the penis islikely the cause of the hematuria and, in this case, aninfection. This could be either gonorrhea or chlamydia.The split specimen results would be similar in the case ofurethral trauma as in vigorous sexual activity. Hematuriafound through all three specimens, total hematuria,points toward bladder or kidney for the cause. Terminalhematuria suggests bladder neck, prostate, or trigoninvolvement.11. The answer is C, E . coli . In complicated UTIs (thoseacquired in anatomically or functionally abnormal tractsor with suspected resistant organisms), the percentage ofcases of cystitis caused by E . coli drops to about 35%, butit remains the most prevalent responsible organism.12. The answer is C. Although in a given clinical settingpainless hematuria cancer may not pose even a majorityprobability of cancer, because of the potentially lifethreateningnature of the cancers, painless hematuriamust be considered to be urinary tract carcinoma untilproven otherwise. The cancers are generally transitionalcell carcinomas of the bladder or renal cell carcinoma (inthe past often called hypernephroma). Occasionally thelesion may be so small as to be missed grossly. Therefore,studies of urine such as cytology or other chemical evaluationof tumor cell by-products are necessary and must berepeated as long as the cause of painless hematuria, particularlymicroscopic hematuria, remains unexplained. Ifhematuria persists and nothing is found grossly, thepatient must be monitored every 6 months. Hemorrhagiccystitis is common in women, usually younger than thewoman presented in the vignette, and is always characterizedby a rapid onset and accompanied by irritativesymptoms (frequency and dysuria). Urolithiasis is in thedifferential diagnosis and must eventually be ruled outbut is rarely unaccompanied by lateralized colicky pain.Pyelonephritis rarely occurs without pain or at least flankor costovertebral tenderness (e.g., in chronic cases), andurinalysis would show pyuria rather than microscopic orgross blood.13. The answer is D. A positive test for leukocyte esteraseis suggestive, but not diagnostic, of bacteria. To be sure,the inference is based on the presumed presence of leukocytes(WBCs). Leukocyte esterase is an enzyme elaboratedby WBCs. However, its sensitivity is compromised by thefalse negatives that can be produced by high specific gravityof the urine, glycosuria, presence of urobilinogen, andmedications including rifampin and ascorbic acid. Furthermore,false positives are produced by specimen contamination.There is a separate dip test for organisms thatreduce nitrate to nitrite. They include many Gram-negativebacteria but not all. The sensitivity of the nitrite test isonly 30%.14. The answer is A, Radionuclide cystogram. Vesicoureteralreflex is the most likely urinary tract abnormalityin this age group and setting. A voidingcystourethrogram is the most common initial diagnostictool but is not used for follow-up because of the radiationexposure. A radionuclide study for reflux involves lessradiation exposure and appears to be more sensitive oncethe fact of reflux is established. Vesicoureteral reflux ismost often secondary to UTI in women and as such isreversible with therapy. In both sexes, anatomic abnormalities,such as a short intramural ureteral segment, precludea functional valve effect. With bladder distentionthe segment fails to shut off retrograde flow of urine withdistention, leading to retrograde spread of infection.Females’ incidence and prevalence are significantly greaterthan males’. However, in males that mechanism accountsfor the vast majority of reflux and upper genitourinarytract spread of infection.15. The answer is A. This statement is wrong. Maleinfants have a greater incidence of UTIs as a group thanfemale infants do. A significant portion of this excessmorbidity, but not enough to account for it alone, isattributed to noncircumcised male infants; thus, Choice Eis a correct statement. All other statements are true. Malechildren over the age of infancy who have a single UTIshould be evaluated for anatomic abnormalities. Femalechildren, especially those over the age of 5 years, may beallowed at least one UTI without such evaluation.16. The answer is B. Cigarette smoking is easily the strongestrisk factor for bladder cancer in western society thatis found in male:females 2:1. Each of the others mentionedis a risk factor, stronger in different times andplaces, except that alcohol is not mentioned as a rankingf a c tor.ReferencesFamily Medicine Board Review 2009. May 3–10, 2009 . KansasCity, Missouri.Kurowski K . Urinary tract infections . In: Rudy DR , KurowskiK , eds. Family Medicine: House Officer Series. Baltimore, MD :Williams & Wilkins ; 1997 : 269 – 284 .Ramakrishnan K , Scheid DC . Diagnosis and management ofacute pyelonephritis . Am Fam Physician . 2005 ; 71 : 933 – 942 .Sharma S , Ksheersagar P , Sharma P . Diagnosis and treatment ofbladder cancer . Am Fam Physician . 2009 ; 80 ( 7 ): 717 – 723.Stoller ML , Carroll PR . Urology . In: Tierney LM , McPhee SJ ,Papadakis MA , eds. Current Medical Diagnosis and Treatment,43rd ed . New York : McGraw-Hill/Appleton & Lange ;2004 : 899 – 940 .U.S. Preventive Service Task Force . Guide to Clinical PreventiveServices , 2nd ed . Washington, DC : Office of Disease Preventionand Health Promotion ; 1996 .