Urology

September 2017

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Clinical Challenge

Volume 46, No.9, September 2017 Pages 703-704

Questions for this month’s clinical challenge are based on articles in this issue. The clinical challenge is endorsed by the RACGP Quality Improvement and Continuing Professional Development (QI&CPD) program and has been allocated four Category 2 points (Activity ID: 109894). Answers to this clinical challenge are available immediately following successful completion online at http://gplearning.racgp.org.au. Clinical challenge quizzes may be completed at any time throughout the 2017–19 triennium; therefore, the previous months’ answers are not published.

Each of the questions or incomplete statements below is followed by four suggested answers or completions. Select the most appropriate statement as your answer.

Case 1

Jack, 40 years of age and previously well, presents with 12 hours of severe colicky left-sided, loin-to-groin pain. On examination, he is afebrile and has mild renal angle tenderness.

Question 1

Which one of the following office-based urine dipstick test results would be most consistent with a diagnosis of uncomplicated renal colic?

  1. Nitrite-positive
  2. A specific gravity of 1.025
  3. Blood-positive
  4. A negative urine dipstick

Question 2

Jack’s test results reveal a 6 mm stone in his left mid ureter. What is the likelihood that this stone will pass with conservative management?

  1. 80%
  2. 60%
  3. 40%
  4. 20%

Further information

Jack’s test results also reveal an incidental finding of a calculus in the right renal calyx. On further questioning, Jack reveals this was noted when he was being investigated for an unrelated problem five years earlier. At that time he was advised that no further action was required.

Question 3

What is the minimum stone diameter that designates you should refer Jack to the urologist?

  1. <1 mm
  2. 1–3 mm
  3. 4–5 mm
  4. >5 mm

Case 2

Ben and his partner, Jasmine, 34 and 33 years of age respectively, have been unable to conceive after trying for 12 months. Jasmine has been thoroughly tested by her general practitioner (GP) and no causes for infertility have been identified. They are wondering if a male factor may be contributing to their difficulties conceiving.

Question 4

In what proportion of couples such as Ben and Jasmine is a male factor the sole contributor?

  1. 3%
  2. 23%
  3. 30%
  4. 50%  

Question 5

Which one of the following investigations should be part of the initial endocrine evaluation for Ben?

  1. Follicle stimulating hormone (FSH)
  2. Afternoon testosterone
  3. Luteinising hormone (LH)
  4. Prolactin

Question 6

You order a semen analysis for Ben. Which one of the following is the correct instruction for Ben regarding specimen collection?

  1. Keep the sample in the fridge until it can be taken to the lab.
  2. Keep the sample at body temperature during transport.
  3. Drop the sample to the lab for analysis within 24 hours of collection.
  4. Abstain from ejaculation for five days prior to collection.

Case 3

Rob, 58 years of age, presents with new onset of difficulty with his erections for the past few months. He says he thinks his penis is now bent, whereas previously it was straight. There is also a lump on the side and he experiences pain in the penis during erections. You suspect Rob may have Peyronie’s disease.

Question 7

At which anatomical site is the penile plaque in Peyronie’s disease most likely to be located?

  1. Right lateral
  2. Left lateral
  3. Ventral
  4. Dorsal

Question 8

Which one of the following comorbidities should you check in Rob’s case?

  1. Diabetes
  2. Raynaud’s disease
  3. Ehler’s Danlos syndrome
  4. Atrial fibrillation

Question 9

Which one of the following treatment options is most likely to correct Rob’s penile deformity?

  1. Low-intensity shockwave therapy
  2. Passive stretching
  3. Pentoxifylline
  4. Surgery

Case 4

Kevin, 47 years of age and previously well, presents for a general check-up. As part of your assessment, you want to ask Kevin about erectile dysfunction, but he seems uncomfortable when you raise the topic.

Question 10

Which of the following statistics could you provide Kevin to normalise a question about erectile dysfunction?

  1. 61% of men over 45 years report erectile dysfunction.
  2. 16% of men over 45 years report erectile dysfunction.
  3. 20% of men aged 60–65 years have erectile dysfunction.
  4. 20% of men in their late 40s with diabetes have erectile dysfunction.

Further information

Kevin reports that he has been experiencing some difficulty achieving an erection during sex with his partner.

Question 11

Which one of the following conditions is Kevin at higher risk of developing?

  1. Prostate cancer
  2. Hypogonadism
  3. Cardiovascular disease
  4. Diabetes

Further information

After further assessment, you discuss a trial of phosphodiesterase inhibitor medication with Kevin, who prefers to have intercourse spontaneously rather than having to plan ahead and for whom cost is not a factor.

Question 12

Which one of the following drug regimens would be most appropriate to trial for Kevin in the first instance?

  1. Vadenafil 5 mg PRN
  2. Tadalafil 5 mg daily
  3. Sildenafil 25 mg PRN
  4. Tadalafil 5 mg PRN

Correspondence afp@racgp.org.au

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