Urology Diagnostic Testing

Question 1

Gonadal Function tests? 3

Answer 1

1. Testosterone
2. FSH
3. LH

Question 2

Symptoms of testosterone deficiency in adult males
1. Decreased what? 4

2. Other symptoms? 3

Answer 2

1. Decreased:
   - energy,
   - libido,
   - muscle mass,
   - body hair
2. • Hot flashes,
   • gynecomastia,
   • infertility

Question 3

Testosterone

1. Produced by what?
2. Stimulates what?
3. Negative feedback loop – testosterone inhibits the production of what?
4. Single most important diagnostic test for what?

Answer 3

1. Produced in the testes by the Leydig cells
2. LH stimulates production
3. Negative feedback loop – testosterone inhibits the production of LH and FSH
4. male hypogonadism

Question 4

1. What to order to evaluate testosterone?

2. Whats the normal range?

Answer 4

1. Measure serum total testosterone

2. Normal range 300-800 ng/dL

Question 5

What combined to make serum total testosterone?

Answer 5

free testosterone + protein bound

Question 6

1. Abnormal testosterone binding to the sex hormone binding globulins: may need a what?
2. If SHBG increased then what?
3. What would cause an increase? 6
4. If SHBG decreased then what?
5. What would cause this decrease?
   8

Answer 6

1. free testosterone test
2. less free testosterone
3. • Aging,
   • hyperthyroidism,
   • increased estrogen,
   • liver disease,
   • HIV,
   • antiseizure drugs
4. more free testosterone
5. • Obesity,
   • insulin resistance,
   • T2DM,
   • hypothyroidsm,
   • increased GH,
   • exogenous androgens,
   • glucocorticoids,
   • nephrotic syndrome

Question 7

Testosterone:

1. Collect sample when?
2. If normal do what?
3. If abnormal do what?

Answer 7

1. Collect sample at 8AM when testosterone levels are the highest
2. If normal – stop testing
3. If abnormal – repeat 1-2 more times to confirm

Question 8

If testosterone is low X 2

What tests should we do?

Answer 8

1. Check LH and FSH
2. Testosterone low and LH and FSH high = primary hypogonadism
3. Testosterone low and LH and FSH not elevated = secondary hypogonadism

Question 9

1. Testosterone low and LH and FSH high = primary hypogonadism from what?
2. Testosterone low and LH and FSH not elevated = secondary hypogonadism from what? 4

Answer 9

1. Klinefelter
2. • T2DM,
   • liver or
   • kidney disease
   • Aging

Question 10

1. What does PSA stand for?
2. Secreted from where?
3. Present where? 2
4. Function?

Answer 10

1. Prostate specific antigen
2. Secreted by the epithelial cells of the prostate
3. • Present in low levels in the serum
   • Present in the semen
4. Function is to liquefy the semen in the seminal coagulum to allow sperm to swim freely

Question 11

Causes of an elevated PSA

Answer 11

1. BPH
2. Prostate cancer
3. Prostatic inflammation or infection
4. Perineal trauma

Question 12

Perineal trauma causes?

3

Answer 12

1. Rarely DRE
2. Bike riding
3. Sexual activity (persists for 48-72 hrs post)

Question 13

Causes of a decreased PSA?

2

Answer 13

1. Obesity

2. Delayed early detection may partially explain worse outcomes in obese men with early prostate cancer

Question 14

Elevated PSA values

1. Indirect measurement of what?
2. Normal values increased with what?
3. Values can vary by what?
4. What time of day should you draw blood?

Answer 14

1. Indirect measurement of prostate glandular size in men without cancer
2. Normal values increase with age
3. Values can vary by race
   Blacks have higher PSA levels than whites
4. Dosent matter. Any day

Question 15

Low PSA levels
Elevated BMI levels may cause lower PSA levels
AND medications. Which meds can reduce PSA levels?
4

Answer 15

1. 5-alpha-reductase inhibitors (50% or greater reductions)
2. NSAIDs
3. Statins 17.4%
4. Thiazides 26%

Question 16

Normal values are controversial as well

1. Normal levels?
2. However what is the problem with this?
3. So what is the most important thing to follow?

Answer 16

1. In the past a value less than 4.0 ng/mL was normal
2. • Men with prostate cancer were found to have values less than 4
   • Men without prostate cancer were found to have values greater than 4
3. Important to follow the trend – how much has the PSA increased over the last year

Question 17

Ongoing research:

1. ___ specific reference ranges
2. Free vs. Total PSA
   - Lower portion of free PSA may be correlated with what?
3. PSA velocity and PSA doubling time are what? 2
4. Pro-PSA
   More strongly associated with what?

Answer 17

1. Age
2. more aggressive forms of cancer
3. • Rate of change in PSA values over time
   • Time it takes to double the PSA
4. prostate cancer than BPH

Question 18

PSA parameters:

3

Answer 18

1. PSA Density (serum PSA/ prostate volume)
2. PSA Velocity (change in PSA over time)
3. Free/Total PSA (PSAII)

Question 19

PSA Density (PSAD)
1. PSA levels are higher in men with what?

2. The PSA density (PSAD) is sometimes used for men with _____ to try to adjust for this.
3. What does it measure?
   - What does it use to measure this?
   - What equation do you get to find the PSAD?
4. A higher PSA density (PSAD) indicates greater likelihood of what?

Answer 19

1. BPH
2. BPH
3. It measures the volume (size) of the prostate
   - with a transrectal ultrasound (TRUS) and
   - divides the PSA number by the prostate volume
4. cancer

Question 20

PSA Velocity (PSAV)
1. PSA velocity is what?

2. A PSA that is changing how is more suspicious for cancer?
3. However, a PSA that is already high or quickly rises to a concerning level will quickly lead to further evaluation
   Usually with a what?

Answer 20

1. the rate of change in PSA over time
2. rising quickly
3. transrectal prostate bx

Question 21

Free/Total PSA(PSAII)
1. Percentage of Free PSA decreases as ________ increases in serum of men with prostate cancer

2. Ratio of f/t PSA, especially in men w/ normal PSA values can be helpful in diagnosing those w/ possible ___?
3. Free and total prostate-specific antigen:
   Only useful with PSA _________ ng/dl

Answer 21

1. Total PSA
2. CA
3. 4.0-10.0

Question 22

Free/Total PSA(PSAII)
1. If the free PSA is elevated in respect to the bound PSA, then the PSA is probably being produced by what?

2. If there is a high level of bound PSA, then it is likely to be manufactured by what?

Answer 22

1. BPH

2. prostate cancer cells

Question 23

Semen analysis

1. Remains the mainstay for what?
2. Abstain from what?
3. Collect how much?
4. Analyze within what time?
5. Obtained by?
6. Turn around for results?

Answer 23

1. Remains the mainstay in investigating male fertility potential
2. Abstain from coitus 2 to 3 days
3. Collect all the ejaculate
4. Analyze within 1 hour
5. Obtained by masturbation
6. Provides immediate information

Question 24

Semen analysis
1. Macroscopic? 3

2. Microscopic? 6

Answer 24

1. Macroscopic
   - Viscosity
   - Volume
   - pH
2. Microscopic
   - Sperm concentration/count
   - Motility
   - Morphology
   - Viability (supravital stain)
   - Leukocyte count
   - Search for immature germ cells

Question 25

Normal semen analysis 1. Volume? 2. Concentration? 3. Initial Forward motility? 4. Normal morphology?

Answer 25

1. >1 cc 2. >2x10^6 cc 3. >50% 4. >60%

Question 26

Semen analysis 1. What is azospermia? 2. What is oligospermia?

Answer 26

1. Azospermia No measurable sperm in the semen 2. Oligospermia Less than 15 million sperm/ml

Question 27

Abnormal Semen Analysis 1. Azospermia causes? 3 2. Oligospermia causes? 4 3. Abnormal volume? 4

Answer 27

1. Azospermia - Klinefelter’s (1 in 500) - Hypogonadotropic-hypogonadism - Ductal obstruction (absence of the Vas deferens) 2. Oligospermia - Anatomic defects - Endocrinopathies - Genetic factors - Exogenous (e.g. heat) 3. Abnormal volume - Retrograde ejaculation - Infection - Ejaculatory failure - Medications

Question 28

1. What is the four glass test used for? 2. Describe it? 4 3. What is each glass tested for? 4

Answer 28

1. PROSTATIC SECRETIONS (chronic prostatitis) 2. - This 4-glass test begins by asking the patient to provide the 10 mL of urine in one glass. - Then, 10 mL of midstream urine is provided in the next glass. - Next, prostatic massage is performed, and EPS is collected in a third glass. - Finally, postmassage urine is collected in the fourth (final) glass.[6] 3. - The initially voided urine is tested for urethral infection, - while the midstream urine is tested for bladder infection. - The EPS fluid is examined for WBCs. - Finally, the postmassage urine is used to flush out bacteria in the prostate that may remain within the urethra.[8]

Question 29

Prostatic massage 1. Avoid in who? 2. Risk for what? 2

Answer 29

1. Avoid in acute bacterial prostatitis | 2. Risk for induction of bacteremia or sepsis

Question 30

Diagnosis of UTI 1. In adults and older children a mid stream urine sample usually reliably represents what? 2. Samples collected from what should not be used to diagnose UTI as they invariably will be contaminated? 3 3. The most reliable sample is obtained via what? 2 (often less traumatic than catheterization)

Answer 30

1. the urine in the bladder (Clean catch) 2. - urinary bags, - pedi-bags or - bedpans 3. - catheterization or - suprapubic aspiration in infants

Question 31

Urine Culture and Sensitivity 1. Gold standard for? 2. Some argue criteria for bacteriuria is only ____ cfu/mL of a uropathogen in symptomatic females or_____ in symptomatic males. 3. Bacterial identification from urine C&S, key in males and females with what?

Answer 31

1. Traditional gold standard for significant bacteriuria >100,000 cfu/mL of urine 2. 100, 1000 3. complicated UTI’s.

Question 32

Sensitivity of Urine C&S: Measurement of sensitivity of bacteria to antibiotics Methods? 2

Answer 32

1. Agar diffusion - Kirby-bauer - discs - Etest - strips 2. Broth dilution

Question 33

Sensitivity tests 1. Solid media looking at? 2. Liquid media looking at?

Answer 33

1. Solid media disc diffusion technique 2. Liquid media minimum inhibitory concentration (MIC) test

Question 34

Bladder Cancer: 1. These patients usually present with what? 2. You will end up getting what? 2 3. The real diagnostic test of course will be the what?

Answer 34

1. painless hematuria 2. UA and some cytology 3. cystoscopy

Question 35

Diagnosis of Bladder Cancer with cytology 1. Microscopic cytology of urinary sediment or saline bladder wash to detect what? (which is more accurate?) 2. Microscopic cytology is more sensitive in what but can be falsely negative in 20% of cases? 2

Answer 35

1. malignant cells. (saline bladder washes more accurate) 2. - high grade tumors or - carcinoma in situ

Question 36

Urodynamics (the function) | 2

Answer 36

1. Peak flow urine rates | 2. Pressure flow study`

Question 37

What do the following measure: 1. Peak flow urine rates? 2. Pressure flow study?

Answer 37

1. Peak flow urine rates - Measures how fast urine is passed 2. Pressure flow study - Urodynamic catheter in bladder - Allows measurement of pressure and urine flow during voiding

Question 38

Urodynamic Assessment 1. Used to assess what? 2. Specifically? 2

Answer 38

1. Used to assess how well the bladder and urethra are functioning 2. - Sphincter control - Bladder filling/emptying

Question 39

Indications: To assess symptoms such as? | 7

Answer 39

1. Urinary incontinence 2. Frequent urination 3. Sudden, strong urges to urinate 4. Painful urination 5. Problems starting a urine stream 6. Problems emptying the bladder 7. Recurrent UTI

Question 40

Urodynamic Testing | 5

Answer 40

1. Uroflowmetry 2. Post-void residual measurement 3. Cystometry 4. Electromyography 5. Video dynamics

Question 41

What does Cystometry measure? | 3

Answer 41

1. Measurement of bladder pressure 2. Measurement of leak point pressure 3. Pressure flow studies

Question 42

Uroflowmetry 1. Screening tool for what? 2. Measure what? 3. Reserved for which pts?

Answer 42

1. Screening tool for patients with suspected bladder outlet obstruction 2. Measures peak flow in mL/sec 3. Reserved for patients with severe symptoms where invasive therapy is considered—done by urologist

Question 43

1. What is PVR? | 2. What are normal values? 2

Answer 43

1. Post-void Residual (PVR) 2. -Less than 50 ml -If patient is > 60 years old normal is 50-100 ml

Question 44

1. Cystometrogram (CMG) is what? 2. How is it done? 2 3. Assesses? 4 Rarely done—invasive—urologist referral!!!!

Answer 44

1. Graphic display of vesical pressure 2. - Bladder is filled with water at a steady rate - Pressure flow study compared with uroflow can distinguish bladder outlet obstruction from impaired detrusor function 3. - Detrusor activity - Sensation - Capacity - Compliance Rarely done—invasive—urologist referral

Question 45

Urethral Pressure Profile 1. Measures what? 2. Indications for testing? 3

Answer 45

1. Measures urethral pressures at multiple levels 2. Indications for testing - Sphincter dysfunction - Urinary incontinence - Detrusor sphincter dyssynergia

Question 46

Video Urodynamics 1. AKA? 2. Combines what kind of measurements? 3. Invasive or non-invasive?

Answer 46

1. AKA Multichannel Fluoroscopic Urodynamics 2. Combines measurement of pressures with uroflow and EMG measurements under radiographic guidance to evaluate interplay between all these functions 3. INVASIVE

Question 47

Chlamydia 1. Dx? 2. Which collection method used in women? 3. IN men? 2 Some available NAATs include the ability to detect Neisseria gonorrhea from the same specimen

Answer 47

1. Nucleic acid amplification tests (NAATs) detect small amounts of chlamydial nucleic acid 2. Vaginal swab preferred in women (Urine ok for women too but vaginal sample more sensitive) 3. - Urine or urethral swab in men - Rectal swabs also may be obtained

Question 48

Gonorrhea 1. Males with suspected urethritis: Dx tests? 2 2. Females with suspected cervicitis or urethritis dx tests? 1

Answer 48

1. Males with suspected urethritis - Microscopy with Gram stain of a urethral swab performs well in men with suspected urethritis - Noninvasive method - nucleic acid amplification testing of urine 2. Females with suspected cervicitis or urethritis - vaginal swab specimen has the best overall sensitivity and specificity