Urology experience

Had urology yesterday. Sometime last week (Friday?) the urology department made a team on MS Teams called “Exam 06.08”, and added the five students who were signed up that day. Also added were Dr. Ákos Pytel, Dr. Miklós Damásdi, Dr. Dániel Bányai and Dr. Kinga Villányi. Naturally, we expected that one of these would be our examiner. Perhaps Dr. Villányi, as she edited the team description after being added.

The day of the exam, just a couple of minutes before 9:00, Dr. Pytel adds Dr. Lehel Péterfi to the team, who ended up being our examiner. One of the students started the meeting the department had scheduled already, and the examiner joined in a few minutes past 9. Next to him sat a young co-examiner.

The examiner introduces himself and warns us that the exam will be recorded. We start by showing ID’s to the camera. Dr. Péterfi tells us that we will each get at least 20 minutes preparation time. He holds up 3 bunches of topics in random order, and tells the students to give him 3 numbers between 1 and 15. I told him number 3, so he picked the third topic from the left. I chose another two numbers to get my other two topics; the other students do the same. He’d hold up the slip of paper with the topic name and give you time to write it down.

The students whose last name was the first in alphabetical order chose topics first and so on, and they were also the first to start. According to the alphabetical order, I was 4th. My exam started approximately 10:40. The exam took place in the meeting, so all of us could hear the other students’ exams.

The recording of the meeting is available to me, so it’s easy for me to write down my whole exam. Even though it hurts to watch and hear myself talk. Appearantly I say “uhh” every second word. Nice!

15. Evaluation and management of urological emergencies: Renal colic, suprapubic pain, acute scrotum, gross haematuria, anuria, and urinary retention

• Me: I’ll start with topic about urological emergencies.
• Examiner: Yes, it’s quite an important topic, even if you’re not a urologist, you have to know this.
• M: So a urological emergency is a condition which causes severe pain, could be life-threatening, or have high risk for permanent disability, or organ loss, which is why it has to be acted on immediately.
• M: The first one in the topic name is renal colic, which is a severe paroxysmal from the flank area, which can radiate to the groin, to the abdomen, to the testicle, to the perineum, etc. It’s most commonly due to ureter or kidney stone, but like the previous student said it can also be due to nephroptosis. It is very painful on percussion and the patient often has an urge to move around. So, the main etiology here is stones. We should do an ultrasound or CT to visualize the stone.
• E: What you’re telling me is good, but try to make it a little more systematic. So we have a patient, he has typical renal colic. What are you going to do?
• M: I would do imaging to look for the stone.
• E: Examining. You should examine the patient before imaging. What kind of imaging should we use?
• M: Ultrasound
• E: That would be the first. Good. What would you expect on the ultrasound.
• M: You could see the stone and its acoustic shadow.
• E: No. Does the stone cause the colic?
• M: Uhh..
• E: It’s a tricky question.
• M: No, the colic is due to the spasm of the ureter muscle.
• E: Yes, the colic can be caused by the stone if that stone is in the ureter. So if the stone is in the kidney the colic is not caused by that stone which is in the kidney; the pain is from the other stone, which is in the ureter. So what do you see there, if some stones are in the ureter? What happens?
• M: We could see dilation of the ureter proximal to the stone.
• E: Yes!
• M: And hydronephrosis.
• E: Well, lets hope no hydronephrosis. Usually in acute pain there is no hydronephrosis. A hydronephrotic kidney has been suffering for such a long time, so there’s no pain. You’ll see dilatation in a kidney with normal parenchyme. So yes, you’ll see dilatation and you might see stones. That’s good about the ultrasound; let’s go further. What else can you do for examining?
• M: You could do a CT.
• E: Yes! What kind of a CT would you do?
• M: I would do a CT urography.
• E: That would be the best, but usually you cannot do that, because the radiologist is going to tell you: “Make an appointment tomorrow or in the next two months”. So then what are you going to do.
• M: Uhmm..
• E: There is a special name for that kind of CT, where they use very low radiation.
• M: Uhmm….
• E: It’s good for looking for stone. It’s like a very good ultrasound. You don’t give contrast. You started saying the name.
• M: *Thinking*
• E: It’s called a low-dose CT. Anyway. So you made a CT, but there is something else which you should do.
• M: You should examine the urine.
• E: Yes! What do you expect in the case of a stone colic?
• M: Haematuria
• E: Yes. Okay. In case of renal colic the biggest problem is differential diagnosis. Could you tell me some diseases which you must differentiate it from? It’s not a renal colic but it goes with the flank pain.
• M: For example pyelonephritis.
• E: Yes, for example. How would you differentiate it from colic?
• M: In pyelonephritis there would be fever, pyuria, leukocyte casts in the urine.
• E: Yes. Very good! Is there anything else in the differential?
• M: Well a tumour could compress the ureter
• E: No. Usually a tumour would compress it so slowly that it doesn’t provoke pain. Instead it would cause a hydronephrosis.
• M: Uhm.. Well if there was trauma, but then the patient would know about that..
• E: You know, the simplest way to think about this is what other organs are around the kidneys.
• M: Okay, so.. Acute appendicits could be in the area..
• E: Very good. You have to differentiate it. How would you do that?
• M: In acute appendicitis you would have tenderness in the McBurney area. You could also do an ultrasound of the appendix.
• E: Well, would there be any dilatation of the kidney?
• M: No.
• E: Would there be any haematuria?
• M: No.
• E: Exactly. The same pain without dilatation and without haematuria should raise the suspicion of the pain originating from somewhere else. Okay, how would you treat a renal colic?
• M: It’s a severe pain, so at least NSAIDs or even opioids. You should also use spasmolytics.
• E: Good. What would be the best spasmolytic? That’s a tricky question because it’s not a drug.
• M: *Thinking*
• E: It’s something for your own knowledge and practice. The best spasmolytic is not a drug.
• M: *Still thinking*
• E: It’s heat. Applying something warm around the muscle. It’s a very good spasmolytic. Something warm around the kidney, or a warm bath; it helps enormously. Let’s go further. Tell me something about the haematuria. There are so many topics that I might just choose some of those.
• M: Okay, so gross haematuria can have many causes. Genitourinary trauma, bladder cancer, acute glomerulonephritis, tubulointerstitial nephritis, papillary necrosis, stone.
• E: Okay. Very good. What could a gross haematuria cause to your patient? Let’s say there’s a male patient who’s got some problems with urination already because of age. This haematuria would aggrevate this situation. Why?
• M: Well if he loses a lot of blood he could get anaemic.
• E: Yeah. He could even get hypovolaemic shock. But I was thinking about urination. We’re urologists, let’s hope we won’t have to save his life. What happens if there’s a lot of coagulum in the bladder?
• M: Okay, then the blood clots could obstruct the lower urinary tract.
• E: Yes, yes. That can cause total retention. What do we do in this case?
• M: So in case of total retention we would have to insert a catheter.
• E: Yes. Good answer. What kind of a catheter would you insert in haematuria?
• M: We would start with a Foley catheter.
• E: No, that would not be the best. The best would be a special catheter.
• M: Oh, sorry. The three-way catheter.
• E: Exactly. We want to wash the blood out, and it’s much easier to do with that one. Yes you’re right. Okay. If we’re not able to insert a catheter, what is the next option?
• M: If we’re not able to insert a three-way catheter or any catheter?
• E: No, no. I jumped to the urinary retention question. What if you’re not able to treat the urinary retention with a catheter?
• M: A suprapubic catheter.
• E: Yes. What would be those problems where you cannot insert a catheter?
• M: If the urethra is totally obstructed.
• E: Okay, what else?
• M: Uhm..
• E: You had a collegue who just answered this question already. There was a condition in which we don’t use catheters.
• M: Uhh….
• E: Transurethral catheters, I mean.
• M: *Still thinking*
• E: It was infections. Acute prostatitis for example, you don’t want to use a transurethral catheter. You don’t want to create an abscess or something, so you use the suprapubic. Okay, I’ll give you a 4 for that. Let’s go to the next topic.

18. Congenital anomalies of the gonads and vesicourethral unit (bladder, urethra)

• Me: I’d like to start with cryptorchidism. The definition is that one or both of the testicles fail to descend into the scrotum. It’s relatively common – it happens in approximately 1% of male newborns. Some risk factors include prematurity and low birth weight. The diagnosis is made clinically after birth that one or both testicles are missing in the scrotum. The testicle could be palpated if it’s in the inguinal canal or in the abdomen, but if it can’t be located by physical examination it should be located by imaging, to differentiate it from ectopic testis. Most cases spontaneously resolve within 6 months after birth, but if they don’t, surgery is needed.
• Examiner: Good. Can you use any drugs for them?
• M: Uhm.. Could you use testosterone?
• E: They used that back in time. There is some hormone therapy you could use but it’s not important. Why is it important to locate the testis if it’s in an ectopic place? What problem could it cause?
• M: If it’s in an ectopic place then it obviously won’t fix itself, so surgical relocation into the scrotum is needed.
• E: Wait. If the testis is in the inguinal canal you could relocate it if the artery is long enough, but if it remains in the abdomen there’s no chance to move it down. What do you have to do and why?
• M: You have to surgically relocate it to the scrotum
• (he just said that you can’t do that lol)
• E: No, you have to completely remove it. Why.
• M: Because that testis has a high chance of becoming cancerous.
• E: Yes. Anyway it’s not going to be functional in that place, so to prevent cancer you should just remove it. Please go further
• M: Okay, we have bladder exstrophy
• E: That’s such an ugly disease, yeah.
• M: Yeah it does not look pretty. I don’t have much to say. The bladder is herniated out through a defect in the abdominal wall. There’s often an associated defect in the pelvis.
• E: Yes. One congenital anomaly rarely comes alone.
• M: It’s also associated with epispadias.
• E: Yes. What is epispadias?
• M: It’s that the urethral orifice is on the dorsal side of the penis.
• E: Yes. And how would you call the other way around?
• M: Hypospadiasis.
• E: Yes.
• M: So the treatment for bladder exstrophy and epispadiasis is surgical, but hypospadiasis only needs to be treated if it’s symptomatic.
• E: Well, usually the patient’s parents want us to fix it either way. Uhm, what else.. You know what, I’ll give you this. This was a small question but the other one was large, so. Let’s move on.

33. Non-tumorous diseases of the penis and urethra

• Me: Okay, so there’s a lot to talk about here. I can start with paraphimosis.
• Examiner: Good!
• Me: .. Which is actually also a urological emergency. It means that the foreskin is retracted but cannot be returned to its original position. This is a problem because it will cause swelling of the glans, which will further worsen the problem. In worse case, if left untreated it can cause necrosis. The treatment is local anaesthesia or regional anaesthesia and try to manually reduce it. If that does not work then a surgical incision of the tight part is performed, or in worse case circumcision.
• E: Good.
• M: Okay, that’s all I have to say about that. There’s also priapism, another emergency. So priapism is a non-sexual erection which lasts for more than 4 hours and is not relieved by ejaculation.
• E: It’s not relieved by any way, but yes.
• M: So we have low-flow and high-flow varieties.
• E: Very good! So what does it mean?
• M: Low-flow means that the problem is decreased venous outflow, while high-flow means that there is increased arterial inflow.
• E: High-flow is usually due to trauma, yes. The venous can be caused by different means. Okay. What do you do.
• M: The initial treatment would be to aspirate blood from the corpus cavernosum. If that doesn’t work then you have surgical opportunities.
• E: I hate those surgical opportunities but yes. There are some drugs you can use, but whatever. Question. How would you differentiate between the two types?
• M: Well the high-flow is often due to trauma, so if no trauma has happened before then low-flow is more likely. But I suppose the best way would be doppler ultrasound.
• E: Doppler ultrasound is a good way but not the best way.
• M: Uhm..
• E: The logic is there. You’ve told me that there is arterial blood in high-flow and venous blood in low-flow. How do you differentiate between the two types of blood. What do they contain?
• M: Okay, you could sample the blood maybe, look for oxygen differences.
• E: Exactly! You make a blood gas analysis of the blood which you just aspirated with a very large needle. Okay! Good. One more question. What is the Peyronie disease related to the penis?
• M: Peyronie disease is an idiopathic disease where you have formation of fibrous plaques in the tunica albuginea. It causes painful erections, abnormal curvature, erectile dysfunction.
• E: Okay. I’m not asking anymore. It’s a five.
• M: Thank you so much sir! Have a good day.
• E: Have a good day!

Epilogue

So, another success story for me. All in all a very good exam experience, especially because of the preparation time, which is so important for me to calm down and collect my thoughts before the exam. My exam took 20 minutes, and the other exams took roughly the same amount of time. The examiner was very nice as well, he did not mind having to re-iterate or repeat questions, and I though he asked very fair questions overall. I didn’t get my grade until this morning, which is always stressful.

I though everyone would draw one topic from each “group” of topics as I have separated them, but as you saw I didn’t get any cancer topics, but another student that day got 2 cancer topics. So I don’t know what’s going on.

For ms. Worldwide urology was the last exam of this semester. I still have public health final. I have it on monday. Not because I think I need one whole week of studying for it, but because I’d rather just study 50% of the day for a week than to stress all day like I have been the last weeks. I am home, my surgery practice starts in July, so I have no rush to finish the exam period, really.

I was supposed to start studying PH again today, but this post took so long, so I’m probably going to start tomorrow. I’ll go over all the PH lectures and all my notes again, trying to fix any mistakes.

Good luck for your exams!