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will have female-typical external genitalia. Patients with CAIS AUA 2023 will have an increased risk of seminoma with time if the testes are...

will have female-typical external genitalia. Patients with CAIS AUA 2023 will have an increased risk of seminoma with time if the testes are left in situ after puberty. Historically, gonads were removed at the SASP 2023 Question 1. time of diagnosis. However, given the relatively low risk of The endopelvic fascia is a continuation of: malignancy, some patients may prefer to retain gonads for A. the levator ani muscle endocrine or reproductive potential. After counseling, if a patient B. the transversals fascia elects to retain the gonads, a malignancy surveillance plan should C. Denonvilliers' fascia be outlined. There is an increased risk for gonadoblastoma in D. the internal oblique fascia dysgenetic gonads when Y chromosome material is present but E. the obturator internus muscle. not in CAIS. Individuals with CAIS are at no higher risk of Leydig cell tumors, embryonal carcinoma, or teratomas than the ANSWER= B general population. The endopelvic fascia is an important structure in pelvic and retropubic urologic surgery, in the pelvis, the viscera including SASP 2023 Question 4. the bladder prostate vagina, and rectum, are all encased within the Non-gonococcal urethritis not responsive to a full course of intermediate statue of retroperitoneal connective tissue which is doxycycline should be treated with: derived from the transversalis fascia Condensations of the A spectinomycin. intermediate stratum form the endopelvic fascia and ligaments of B. ceftriaxone. the pelvis, including the pubourethral puboprostatic, and C. amoxicillin-clavulanic acid. pubocervical ligaments, the arcus tendonous of the endopelvic D. penicillin. fascia, the broad ligament of the uterus, and the lateral vesical E. azithromycin. pedicle. The levator ani muscle, Denonvilliers fascia, the internal oblique fascia, and the obturator internus muscle are not ANSWER: E continuations of the endopelvic fascia Non-gonococcal urethritis caused by Chlamydia trachomatis or Ureaplasma urealyticum cannot be distinguished from one SASP 2023 Question 2. another clinically, but either doxycycline or azithromycin is Detumescence of the penis is mediated by: usually effective against both. Sexual partners should also be A. Acetylcholine treated. If the signs and symptoms of urethritis do not improve B. vasoactive intestinal polypeptide. with doxycycline, infection with resistant U. urealyticum may be C. Cyclic GMP present, this usually responds to azithromycin. Relapse may be D. prostaglandin due to reinfection by an untreated sexual partner, and the patient E norepinephrine and all partners should be retreated. Currently, the initial recommended therapy is doxycycline, 100 mg twice daily for two ANSWER= E weeks, or a single 1 gram dose of azithromycin, which can be When the penis is flaccid, the smooth muscle of the penile vessels repeated after 10 to 14 days if needed. Other alternatives include and of the lacunar spaces are in a state of tonic contraction, erythromycin, 500 mg four times daily, or ofloxacin, 300 mg maintained by post-ganglionic sympathetic adrenergic nerves, twice daily for 10 to 14 days. The other antibiotic choices which release norepinephrine as their primary neurotransmitter (spectinomycin, ceftriaxone, amoxicillin-clavulanic acid, Parasympathetic stimulation causes erection through non- penicillin) are not indicated for the treatment of nongonococcal adrenergic, non-cholinergic neuronal release of nitric oxide urethritis. which subsequently leads to a generation of cyclic GMP, and ultimately relaxation of penile smooth muscle. Acetylcholine, ASP 2023 Question 5. vasoactive intestinal polypeptide, cyclic GMP, and prostaglandin During metabolic stone evaluation, a 35-year-old man has a would all result intumescence rather than detumescence. urine pH of 5.45 and total urinary uric acid of 368 mg/day (normal < 650 mg/day). His urinary uric acid level rises to SASP 2023 Question 3. 1,079 mg/day after one month of potassium citrate therapy. A 16-year-old phenotypic girl undergoes evaluation for The rise in his urinary uric acid level is due to: primary amenorrhea. Testes are found on laparoscopic A increased dietary purine intake. examination. Karyotype is 46,XY. If the gonads are not B. increased purine turnover. removed, the tumor most likely to develop is: C increased production of endogenous uric acid. X A.seminoma. D. resuspension of urinary uric acid. B. Leydig cell tumor. E. inhibition of xanthine oxidase. C. gonadoblastoma. D. embryonal carcinoma. ANSWER=D E teratoma. Examination of the initial 24-hour urine collection from this patient would note small white crystals at the bottom of the urine ANSWER= A container. These are uric acid crystals that have precipitated out Complete androgen insensitivity syndrome (CAIS) is due to the of solution. Uric acid precipitation is due to the urine pH being absence of a functional androgen receptor. All affected below the pKa of uric acid (less than 5.5). Once the urine pH is individuals will have a 46,XY genotype and approximately 90% raised above 5.5 with alkali therapy (in this case, potassium 1|Page citrate), the uric acid will go back into solution and the true C. radiation scatter from the patient. solubilized uric acid level can be calculated by analysis of this D. radiation scatter from endoscopic instruments. 24-hour urine specimen. An increase in dietary purine intake E. radiation scatter from the operating room walls and floor. would also decrease urine pH and, therefore, would increase uric acid supersaturation but not necessarily increase the urinary uric ANSWER=C acid levels. Increased purine turnover or increased production of Scattering of the primary beam from the patient is the primary endogenous uric acid would not be associated with potassium source of radiation exposure to the operator during endourologic citrate therapy and are generally the result of chemotherapy or procedures. For this reason, maximizing the distance between the inherent genetic defects such as Lesch-Nyhan syndrome. operator and the patient during fluoroscopy is a very effective Inhibition of xanthine oxidase would decrease uric acid levels.’] method of reducing exposure. This explains why the fluoroscopy source is best placed under the patient to minimize radiation SASP 2023 Question 6. scatter to the operator. Radiation scatter from other sources, the A 55-year-old woman, who had a sacral neuromodulation primary radiation beam, or leakage from the x-ray tube are less implant placed four years ago, has declining efficacy despite significant sources of exposure. several reprogramming sessions. A plain film x-ray is shown. The next steps are to remove the lead and: SASP 2023 Question 9. A 27-year-old man with erectile dysfunction has a mean (Image not available from the source) cavernous artery peak systolic velocity of 30 cm/sec at five A place new lead deeper. and 20 minutes after the intracavernous injection of 10 mcg B. place new lead more laterally. of PGE-1. He achieves a full erection during this testing C. place new lead in 54. situation. The most likely explanation for his erectile D. place new lead more medially. dysfunction is: E. remove implantable pulse generator (IPG) and inject 200 units A. veno-occlusive dysfunction. of onabotulinumtoxinA. B. arterial insufficiency. C. veno-occlusive dysfunction and arterial insufficiency. ANSWER=:D D. psychogenic dysfunction. The plain films show the lead is too lateral and too deep in the $3 E. neurogenic dysfunction. foramen. The use of a curved stylet would allow placement of the new lead into S3 in a more medial-to-lateral configuration, ANSWER=D thereby allowing maximal contact of electrodes to the nerve. This Penile ultrasound is commonly used in the evaluation and is due to the nerve following a medial-to-lateral course. Revising management of men with erectile dysfunction, Peyronie's leads to place them deeper may create stimulation of the leg and disease, and other sexual dysfunctions. The vascular assessment other untoward effects. S4 lead replacement is not recommended. portion of the ultrasound evaluates the peak systolic velocity, Lateral lead placement would not allow optimal contact with the end-diastolic velocity, and resistive index. Although definitions nerve. It would be premature to remove the system and start vary slightly, a peak systolic velocity of < 25-30 cm/sec suggests onabotulinumtoxinA injections. Furthermore, if ultimately arterial insufficiency, while an end-diastolic velocity of >5 utilized, the dose of onabotulinumtoxinA used for OAB is 100 cm/sec suggests veno-occlusive dysfunction, and a resistive units. index of < 0.80 suggests veno-occlusive dysfunction. However, it is important to recognize that the findings on vascular SASP 2023 Question 7. assessment should not take precedence over clinical findings. If a The nerve supply of the adrenal gland is: patient is found to have arterial insufficiency or veno-occlusive A. parasympathetic to medulla. dysfunction but does not experience symptoms of erectile B. sympathetic to medulla. dysfunction, then the vascular findings on penile ultrasound are C. parasympathetic to cortex sympathetic to medulla. of minimal consequence. In the current example, the peak systolic D. sympathetic to cortex and medulla. velocity of 30 cm/sec rules out arterial insufficiency. Similarly, E. sympathetic to cortex parasympathetic to medulla. since the patient is achieving a full erection with intracavernous injection, veno-occlusive dysfunction can be ruled out even in the ANSWER=B absence of knowing the end-diastolic velocity. Neurogenic The only nerves to the adrenal which have been demonstrated are dysfunction cannot be assessed with a penile ultrasound. Of the sympathetic branches from T/10-L/1 coursing through the available choices, psychogenic dysfunction is most consistent splanchnic nerves. This preganglionic sympathetic input with the findings presented. stimulates the release of catecholamines from the adrenal chromaffin cells. Cortical innervation or parasympathetic SASP 2023 Question 10. innervation have not been demonstrated. A 36-year-old man with ejaculatory duct obstruction and a left varicocele has persistent azoospermia despite SASP 2023 Question 8. normalization of ejaculatory volume following TUR of the The principal source of operator radiation exposure during ejaculatory duct. The next step is: endourologic procedures is: A. TRUS. A. the primary radiation beam. B. repeat TUR of the ejaculatory duct. B. radiation leakage from the x-ray tube. C. scrotal exploration and testis biopsy. 2|Page D. varicocelectomy. hyperoxaluria. In addition, these patients lose fluids and E. donor insemination. bicarbonate from their chronic diarrhea, causing decreased urine output and hypocitraturia, respectively. Magnesium levels are ANSWER=C also decreased in these individuals. This combination may cause Persistent azoospermia following resection of the ejaculatory recurrent calcium oxalate stone formation. Appropriate ducts may be due to persistent obstruction, concomitant management of chronic diarrheal syndromes includes increased epididymal obstruction, or testicular failure. The restoration of hydration, alkalinization, and calcium supplementation, to bind normal ejaculate volume rules out persistent ejaculatory duct free oxalate in the intestine. Calcium and magnesium are often obstruction, and therefore, neither a repeat TUR-ejaculatory duct decreased, not increased, in the urine of affected patients. Uric nor a TRUS is indicated. Scrotal exploration is necessary to acid levels in the urine are generally not affected, and with differentiate between epididymal obstruction and testicular bicarbonate loss in the stool, the urine is generally acidic. failure. Donor insemination is not necessary with obstructive azoospermia unless the obstruction is uncorrectable and the couple refuses ICSI/IVF. Varicocelectomy may be indicated in SASP 2023 Question 13. some instances of non-obstructive azoospermia but it is not In a patient with clear cell RCC, the metastatic site with the helpful with obstructive azoospermia. worst prognosis is: A. liver. SASP 2023 Question 11. B. bone. The chemotherapeutic agent used to treat urothelial C. lymph nodes. carcinoma that may be associated with increased absorption D. lung. in patients with a continent diversion is: E. adrenal gland. A. methotrexate. B. 5-FU. ANSWER=A C. vincristine. The most common location of metastasis in patients with clear D. cisplatin. cell RCC is the lung (70%), lymph nodes (459%), bone (32%), E. doxorubicin. liver (1896), adrenal gland (10%), brain (89%), and pancreas (59%). In a large multi-institutional series, the median survival ANSWER=A rates of patients with liver, bone, lymph nodes, lung, and adrenal Although chemotherapy is generally well tolerated in patients gland metastasis are 17.6, 19.4, 214, 25.1, and 27.3 months, with urinary diversion, methotrexate toxicity has been respectively. Patients with brain metastasis have a median documented. Methotrexate toxicity can be compounded in survival rate of 16.5 months. patients who require adjuvant therapy after radical cystectomy and neobladder or continent cutaneous diversion due to SASP 2023 Question 14. reabsorption of this agent by the intestinal segment. Vigorous The most frequent complications associated with the use of hydration and alkalinization of the urine along with liberal mitomycin C for intravesical therapy are: leucovorin rescue are indicated to reduce the likelihood of this A. chemical cystitis and rash. complication. In patients with continent diversion receiving B. myelosuppression and rash. chemotherapy, consideration should be given to pouch drainage C. flu-like symptoms and myelosuppression. during drug administration. 5-FU is rarely used in the treatment D. contracted bladder and chemical cystitis. of metastatic bladder cancer. Cisplatin, doxorubicin, and E. myelosuppression and chemical cystitis. vincristine are not reabsorbed by ileal mucosa. ANSWER=A Rash occurs in 9% of patients receiving mitomycin C instillations SASP 2023 Question 12. and may represent a contact dermatitis. Chemical cystitis has A 51-year-old woman has formed eight stones over the been reported in 6-41% of patients managed with this agent. The previous three years. Past medical history is significant for molecular weight of mitomycin C is so high that little is absorbed, intermittent UTIs and Crohn's disease with persistent watery and myelosuppression is rare. A contracted bladder is also rare diarrhea. The most likely finding during metabolic evaluation after mitomycin C treatment. Flu-like symptoms, which are is hyperoxaluria and: commonly seen after BCG therapy, are uncommon after A. hypercalciuria. intravesical chemotherapy. B. hyperuricosuria. C. hypermagnesuria. SASP 2023 Question 15. D. hypocitraturia. A 32-year-old woman has a malodorous fishy vaginal E. alkaline urine. discharge. She has a single male partner and uses an intrauterine device for contraception. The next step is: ANSWER=D A. remove her intrauterine device. Patients with chronic diarrheal syndromes, including regional B. metronidazole for the patient. enteritis or extensive small bowel resection will develop C. metronidazole for the patient and her partner. malabsorption of fat with intraluminal calcium saponification. D. ciprofloxacin for the patient. This provides an increased oxalate load to the colon with resultant E. ciprofloxacin for the patient and her partner. 3|Page  irrigation will not deal with the stones despite the fact that these ANSWER=B are most likely struvite stones. SWL and endoscopic or Bacterial vaginosis results from a replacement of normal vaginal percutaneous lithotripsy are not indicated in these cases as it is flora of Lactobacillus species with high concentrations of impossible to remove all of the stone fragments which can anaerobic bacteria. Diagnosis can be confirmed with the subsequently act as a nidus for recurrent stone formation. identification of clue cells, a homogenous vaginal discharge, a Although endoscopic approaches can be used, they risk damage vaginal pH > 4.5, and a malodorous fishy vaginal discharge. Risk to the efferent continence mechanism. Percutaneous approaches factors may include multiple sexual partners, a new sexual can be considered for smaller volume calculi in which case the partner, use of an intrauterine device, and douching. stones should be removed intact if at all possible. The simplest Metronidazole (oral 500 mg bid for seven days) or intravaginal method to render the patient stone-free is open stone removal, and gel (0.75%) is the treatment of choice for the patient. the CT scan demonstrates a favorable body habitus with no bowel Clindamycin intravaginal cream (29%) is an alternative. Routine anterior to the pouch. There is no evidence indicating a need to treatment of sexual partners is not recommended. Ciprofloxacin revise the pouch given no hydronephrosis of the upper tract and or removal of the IUD is not indicated. Symptoms may recur in no comment on incontinence. one-third of patients after treatment. SASP 2023 Question 18. SASP 2023 Question 16. Patients with cystinuria excrete excess amounts of: During surgical exploration of the left kidney, the first major A. glycine. branch of the renal artery is transected. The renal segment most B. aspartic acid. likely supplied by this branch is: C. arginine. A. apical. D. L-glycerate. B. upper anterior. E. glycolate. C. middle anterior. D. lower anterior. ANSWER=C E. posterior. Cystinuria is due to a defective neutral, dibasic amino-acid transporter. The gene has been located on chromosome 2. This ANSWER=E results in excess urinary excretion of cystine, ornithine, lysine, The first branch of the left renal artery is a small ureteral branch, and arginine. The latter three amino acids are quite soluble in but the first major branch is the posterior or dorsal artery. This urine, whereas cystine is not. Glycine, aspartic acid, L-glycerate, artery primarily supplies the posterior segment of the kidney and glycolate are not affected by the defective dibasic amino-acid alone but occasionally may provide a small branch to the apical transporter and are therefore not increased in the urine in patients segment as well. The anterior or ventral artery generally supplies with cystinuria. branches to all but the posterior segment, including the apical, lower, upper, and middle anterior arteries. SASP 2023 Question 19. A 68-year-old man has a posterior bladder injury during a SASP 2023 Question 17. low anterior resection for locally advanced colon cancer that A 70-year-old woman develops recurrent UTIs ten years after is repaired primarily with a two-layer repair. continent catheterizable diversion. Urine culture grows Postoperatively, a urethral catheter is left indwelling. Serial Proteus mirabilis and urine pH is 7.5. CT scan is shown. The postoperative cystograms obtained at three, six, and nine next step is: weeks following surgery reveal persistent extraperitoneal extravasation from the posterior bladder wall. A CT scan reveals no pelvic masses and no evidence of ureteral injuries. The next step is A. repeat cystogram in three weeks. B. cystoscopy and fulguration. C. cystoscopy and biopsy. D. primary repair and omental interposition. E. suprapubic cystostomy. ANSWER=C A. antibiotics and Rimocidin irrigation. Persistent drainage nine weeks following a repaired bladder B. SWL. injury would indicate issues related to poor healing such as the C. endoscopic lithotripsy. presence of a foreign body, inadequate drainage from an D. open cystolithotomy. indwelling catheter, or recurrent/persistent malignancy. This E. open cystolithotomy and pouch revision. injury is unlikely to heal with further catheter drainage following nine weeks of observation; therefore, waiting an additional three ANSWER=D weeks and repeating a cystogram would be of little to no value. Continent cutaneous urinary diversions develop stones in The next step should be a cystoscopy and biopsy to rule-out approximately 10% of cases. Frequent catheterization and pouch recurrent/persistent malignancy before proceeding with irrigation can help to reduce the risk. In this case, antibiotics and definitive therapy. Assuming the urethral catheter is working 4|Page appropriately, suprapubic drainage will not be any more effective intact sensation (pudendal nerve) and the and will not resolve the issue. Fulguration of a fistula tract and/or parasympathetic/sympathetic systems (hypogastric plexus, injection of fibrin glue has been shown to be of benefit in fistula cavernosal nerves). In the current scenario, a T12 spinal injury < 5 mm in size, with definitive surgical repair pursued in large or has been sustained, which will allow for reflexogenic erections persistent fistulas. Surgical intervention, however, should not be (intact sensation/parasympathetic system) but will limit pursued until persistent or recurrent malignancy has been ruled ejaculation (due to damage of the spinal ejaculation generator). out. Further, definitive surgical intervention should be delayed The individual would also not feel pleasure or a sensation of for three months after the low anterior resection to allow orgasm with the reflex erection/ejaculation. inflammation to subside. SASP 2023 Question 22. SASP 2023 Question 20. An 80-year-old obtunded man has urinary retention. He has The drug that may result in a false-positive screening test for bilateral pitting edema, an elevated jugular venous pulse, and urinary opiates is: a blood pressure of 200/120 mmHg. His creatinine is 4.0 A. ampicillin. mg/dL. The serum K+ and Na+ are normal. An ultrasound B. cephalexin. shows a very distended bladder and bilateral pelvicaliectasis. C. trimethoprim. Three liters of urine is obtained from his bladder when he is D. ciprofloxacin. catheterized. Urine output over the next two hours is 700 mL. E. nitrofurantoin The next step is:. A. serial creatinine measurement. ANSWER=D B. replace output mL per mL with DS 1/2 NS. Urinary drug screening is now routinely performed in a number C. monitor fluid intake and output every four hours. of settings. It is important to recognize that certain types of D. monitor postural blood pressure for two hours. antibiotic therapy may result in false positive urinary opiate E. spot check urine for osmolality, sodium, and potassium. testing. Several types of quinolone agents including levofloxacin, ofloxacin, ciprofloxacin, norfloxacin, trovafloxacin, enoxacin, ANSWER=E and nalidixic acid have this property. Rifampin therapy and Post-obstructive diuresis is defined as urine output> 200 mL/hour poppy seed ingestion have also been reported to result in false for two consecutive hours or > 3L/24 hours and is a common positive urinary opiate testing. The other antibiotics listed do not occurrence after relief of bladder outlet obstruction, bilateral cause false positive results. ureteral obstruction, or ureteral obstruction of a solitary kidney. Patients should be closely monitored for high salt and water SASP 2023 Question 21. elimination. High-risk patients include those with chronic A 16-year-old boy has a complete T12 spinal cord injury. obstruction, edema, congestive heart failure, hypertension, After spinal shock resolves, he is likely to have: weight gain, and azotemia. In the high-risk patient, a spot check A. no erection, poor ejaculation. urine for osmolality or specific gravity will assess the kidney's B. no erection, vibratory ejaculation. ability to concentrate or dilute the urine to maintain fluid balance. C. reflexogenic erection, vibratory ejaculation. Assessment of urine electrolytes may also guide the type and D. reflexogenic erection, poor ejaculation. duration of fluid replacement. High-risk patients such as this one E. psychogenic erection, poor ejaculation. should have vital signs, including postural blood pressure and output measured hourly. D5 1/2 NS is an appropriate replacement ANSWER=D fluid in the patient who cannot consume oral fluids and/or who Patients with suprasacral spinal cord injuries typically have has poor cognitive status, and/or clinical hypotension. This preservation of reflexogenic erections, but not psychogenic or replacement fluid is given at half of the previous hour's urine nocturnal erections, which require central neural integration. The output. Fluids should not be replaced at an equal rate of output penis receives innervation via several different nerve pathways because this may prolong the diuresis. and branches. Penile sensation and muscular contraction of the bulbospongiosus muscles are both innervated by the pudendal SASP 2023 Question 23. nerve, which receives roots from the 52-4 spinal region. The A 26-year-old pregnant woman at 22 weeks' gestation has parasympathetic nerves, which are predominantly responsible for intractable left-sided back pain. She is afebrile. Catheterized generating erections, originate in the 52-4 region and travel urinalysis shows 5-10 WBC/hpf. Ultrasound of the left kidney through the hypogastric plexus into the cavernosal nerves. The is shown. The right kidney is normal. She refuses CT scan. cavernosal nerves then travel posterior to the prostate (often The next step is empiric antibiotics and: injured during prostate surgeries) and enter the corpus cavernosum. The sympathetic nerve pathway originates in the T10-12 spinal roots and travels in the paravertebral sympathetic chain. Sympathetic branches are then dispersed to the hypogastric, cavernous, and pudendal nerves. Ejaculation is also specifically mediated in the T12-L2 region, in the spinal ejaculation generator. Nerves traveling to the brain help initiate the sensation of orgasm and pleasure. With the above background in mind, vibratory ejaculation is a reflex that is dependent on 5|Page A. observation. ANSWER=E B. hydration and medical expulsive therapy. In men with recurrent bouts of ischemic priapism who desire to C. non-contrast MRI scan. preserve their sexual function, the use of an LH-RH agonist is D. cystoscopy and retrograde pyelography. problematic due to a significant number of adverse effects related E. PCNT. to the suppression of testosterone. In this situation, training the patient to use home intracavernosal injections with phenylephrine ANSWER=C is warranted. The literature supporting the use of oral terbutaline, Hydronephrosis of pregnancy is at least two to three times more digoxin, or baclofen is variable and does not demonstrate common on the right side than on the left. Isolated left-sided equivalent consistency or efficacy compared to phenylephrine. hydronephrosis during pregnancy should prompt investigation into other causes of urinary tract obstruction, such as a stone. The SASP 2023 Question 26. presence of leukocytes in the urine suggests the possibility of A 45-year-old man develops irritative symptoms and a fever infection combined with obstruction and mandates investigation. of 39° C after beginning induction intravesical BCG therapy. Transvaginal ultrasound, looking for ipsilateral absence of the The fever persists for three days despite administration of ureteral jet, would be the initial screening study, if available. In acetaminophen. Urinalysis reveals microscopic hematuria. this scenario, a non-contrast MRI scan would be the study of After stopping BCG, the next step is: choice as the patient refuses the CT scan. Low-dose CT scan is A ciprofloxacin for one week. considered low-risk in pregnancy and has a high positive B. ciprofloxacin for one week followed by suppressive antibiotic predictive value for stones. PCNT and retrograde pyelography therapy. would not be indicated in this setting unless less invasive C. Isoniazid for three months. diagnostic studies were unrevealing or demonstrated a need for D. isoniazid and rifampin for six months. intervention. Observation and hydration with medical expulsive E. isoniazid, rifampin, and ethambutol for six months. therapy are not appropriate next steps given the need to evaluate further the cause of her intractable pain. ANSWER=C Intravesical BCG is generally well-tolerated, but patients should SASP 2023 Question 24. be monitored for systemic infection with BCG and treated A three-year-old boy who underwent surgical correction for appropriately. In the absence of bacteriuria, patients with a high imperforate anus is unable to be toilet trained. VCUG persistent high-grade fever (38.5 degrees or greater) that does not reveals a large trabeculated bladder, grade 3 left VUR, and respond to antipyretic therapy should have BCG treatment incomplete bladder emptying. Ultrasound of the abdomen discontinued and isoniazid (INH) therapy started. This may be an shows two normal kidneys. The next step is: early sign of a systemic BCG infection. Double and triple therapy A. spinal ultrasound. is reserved for patients who present with pulmonary or hepatic B. spinal MRI scan. involvement with BCG. Fluoroquinolones alone or with C. alpha-blocker. suppressive antibiotics are appropriate for treatment of acute D. CIC. bacterial cystitis as opposed to the presumed mycobacterial E. vesicostomy (BCG-related) infection, as is illustrated in this case. It should be. noted that fluoroquinolones may have a role in treating systemic ANSWER=B infections with BCG, but this is as a part of an antimycobacterial Spinal cord abnormalities, including tethered cord or thickened regimen over a more prolonged period and only in the second or or fatty filum terminale and lipoma have been noted in 20-50% third line. of patients with imperforate anus. The severity of the lesion is proportional to the severity of the rectal lesion. In this case, the SASP 2023 Question 27. patient has a high-imperforate anus. VCUG reveals trabeculation, A 55-year-old man with hypertension and erectile VUR into one kidney, and incomplete bladder emptying - a dysfunction, treated with amlodipine 10 mg and sildenafil 25 collection of findings potentially due to neurogenic bladder mg, has LUTS and an IPSS score of 18. His prostate exam is dysfunction. The next step is a spinal MRI scan. Due to benign. He opts for alpha-blocker therapy. He should be ossification of the spine, a spinal ultrasound cannot rule out a instructed to: tethered spinal cord after three months of life. Vesicostomy, CIC, A. switch to vardenafil and medications are premature at this point without UDS and a B. use tamsulosin 0.4 mg daily. formal diagnosis of neurogenic bladder. C. use tamsulosin 0,4 mg daily separated by four hours from sildenafil. SASP 2023 Question 25. D. use tamsulosin 0.4 mg daily separated by 12 hours from A 28-year-old man who is sexually active has recurrent sildenafil. episodes of ischemic priapism requiring visits to the E decrease amlodipine dose before combining tamsulosin and emergency department. The best treatment is: sildenafil A terbutaline. B. LH-RH agonist ANSWER=B C. digoxin, The use of sildenafil 25 mg has no impact on the type of alpha- D. baclofen. blocker used, its dose, or the timing in relation to sildenafil use. E. home intracavernosal phenylephrine. Sildenafil doses greater than 25 mg (50 mg or 100 mg) used to 6|Page require separation from any alpha-blocker by a period of four hours, but recent studies have shown that there is little difference in hypotension with the addition of alpha-blockers to all three doses of sildenafil, so this is no longer recommended. Tadalafil may be used at any dose with tamsulosin 0.4 mg. The concerns about hypotension induced by the concomitant use of sildenafil and alpha-blockers also pertain to vardenafil. Further, there is no need to decrease the dose of amlodipine because of the fact that the combination of sildenafil 25 mg and tamsulosin is considered safe. SASP 2023 Question 28. A 28-year-old man with Kallmann syndrome is treated with A. the study should be repeated with higher voided volume. exogenous testosterone. He desires a biological child. Semen B. he is at high risk for retention in ten years. analysis reveals a volume of 2.2 mL and azoospermia. The C. he is likely to have an elevated IPS. next step is to stop exogenous testosterone and: D. obstruction cannot be differentiated from underactive bladder. A. obtain a post-ejaculate urinalysis. E. symptom improvement after TURP would be worse than if B. obtain serum testosterone, LH, and FSH levels. peak flow rate was greater than 15 mL/sec. C. administer GnRH. D. administer hCG and recombinant FSH. ANSWER=D E. extract testicular sperm for IVF. Uroflow evaluation with the determination of urinary residual is an important screening tool for patients with lower urinary tract ANSWER=D symptoms. Normal values vary depending on age, sex, and Kallmann syndrome, anosmia or hyposmia associated with volume voided. In men, urine flow declines with age, while hypogonadotropic hypogonadism, is commonly diagnosed due to women will have minimal alterations with age. In general, in pre- a delayed onset of puberty. Most patients are treated with pubertal males and females, the average peak flow rates range exogenous testosterone at the time of their diagnosis for from 10-15 mL/sec. Post-puberty until age 45 years, the average virilization. Testosterone is easy and cost-effective to administer peak uroflow rate in males is 21 mL/sec. The average peak flow compared to daily injections of alternative hormones. rate for females is 18 mL/sec. Between the ages 46 to 65 years, Azoospermia in these patients results from the combination of the average peak uroflow rate for males will decrease to 12 inadequate levels of intratesticular testosterone and the patient's mL/sec. The average peak uroflow rate for females will remain at natural absence of stimulatory pituitary hormones. When the 18 mL/sec. Between 66 to 80 years of age, the average peak patient desires to father children, spermatogenesis can be brought uroflow rate for males will further decrease to 9 mL/sec. The about by discontinuing exogenous testosterone and beginning average peak uroflow rate for females remains at 18 mL/sec. daily IM or SQ injections of hCG and recombinant FSH. GnRH While flow rates decrease in men with age, this patient's uroflow administration may be considered but is expensive and requires results are within normal limits for his age and would not predict I.V. administration. In patients with low ejaculate volume (< 1.5 future risk of urinary retention. In general, provided the patient mL), post-ejaculate urine is useful to diagnose retrograde voids a minimum of 125-150 mL, urologists will find a peak flow ejaculation; however, this patient's ejaculate volume is normal. rate of 15 mL/sec in one-third of patients evaluated (one standard Assay of testosterone, LH, and FSH is not needed in this patient deviation below the mean) and a peak flow rate of 12 mL/sec in in whom a diagnosis of Kallmann syndrome has already been 5% (two standard deviations below the mean). In using the made. It would be inappropriate to proceed with testicular sperm uroflow to evaluate patients, it is critical to note the following: 1) extraction without first giving the hormonal treatment necessary The uroflow represents the combined dynamics of the outflow to stimulate spermatogenesis. tract and detrusor contractility, a decrease in peak uroflow may be due to either the obstruction of the outflow tract, poor detrusor contractility, or both; 2) There is minimal to no correlation of the peak uroflow to IPSS. Specifically, pharmacological therapy for BPH will frequently document significant improvement in SASP 2023 Question 29. symptom scores with minimal to no increase in peak uroflow; 3) A 60-year-old man with urinary urgency and sense of Studies have found that patients with a peak uroflow of 15 mL/sec incomplete emptying undergoes a non-invasive uroflow as have significantly less improvement in IPSS following TURP shown. He has a PVR of 100 mL. Based on these results: compared to patients with a peak uroflow of < 15 mL/sec. The uroflow, being of prognostic value in this circumstance, enables the surgeon to determine how well surgical intervention will improve the patient's symptoms. SASP 2023 Question 30. A 72-year-old man on ADT has difficulty voiding 30 months following brachytherapy for localized prostate cancer and undergoes TURP. Before brachytherapy, his prostate volume 7|Page was 30 mL, his PSA was 5.2 ng/mL and IPSS was 7. The factor side effects and are no longer first-line treatment. Observation is most likely to correlate with incontinence following TURP is: not recommended since this patient is symptomatic at this time. A. pre-operative PSA A history of asymptomatic bacteriuria or recurrent symptomatic B. prostate volume. UTIs in women typically does not require cystoscopy or imaging C. treatment with ADT, studies, according to the AUA Guideline on Recurrent UTIs in D. time since brachytherapy. Women. Single dose therapy is inadequate in this setting. E. pre-operative IPSS. Initiating estrogen therapy in patients with recurrent symptomatic UTIs and atrophic vaginitis in a post-menopausal woman would ANSWER=D be appropriate. However, treating with estrogen alone in a setting Rates of incontinence can be high in patients undergoing TURP of an acute symptomatic infection is insufficient. following brachytherapy (at least 189%). The presence of obstructive symptoms at the time of TURP and a period of at least SASP 2023 Question 33. two years since brachytherapy are associated with a greater A 52-year-old woman develops continuous leakage of clear likelihood of incontinence. Treatment with ADT, prostate size, fluid from her vagina six weeks following a laparoscopic pretreatment IPSS, dosage of brachytherapy, and pre-treatment hysterectomy for benign disease. A CT urogram is normal PSA do not seem to affect the likelihood of incontinence. and cystoscopy reveals a subtrigonal 1 cm vesicovaginal fistula between the posterior wall of the bladder and the mid- SASP 2023 Question 31. vagina. The next step is A 58-year-old woman returns to the office two months A placement of urethral catheter and repeat evaluation in six following sacral neuromodulation with a low-grade fever and weeks. incisional drainage associated with pain and erythema over B. cystoscopy and fulguration of the fistula. the implantable pulse generator (IPG) site. The next steps are C. immediate transvaginal repair, explanation of the IPG and: D. immediate transabdominal repair. A. observation. E. transabdominal repair in three months. B. lead. C. wound irrigation, and reimplantation of the IPG. ANSWER=C D. lead with simultaneous test stimulation of a new lead. Because of its size, the fistula is unlikely to close with prolonged E. simultaneous placement of an IPG on the contralateral side. Foley catheterization. There is limited data to support endoscopic treatment with fulguration for genitourinary fistulas. In this ANSWER=B patient, immediate surgical repair is indicated. The outcomes are This patient has signs and symptoms of an infected IPG. The not adversely affected by intervening at six weeks. Given the bacterial infection of the IPG will result in a bacterial biofilm that location of the fistula, a transvaginal approach with interposition will also contaminate the lead connected to the IPG. Thus, both of labial or peritoneal flaps between the vesical and vaginal the IPG and lead should be explanted, and the patient should be tissues at the time of repair would be optimal, given high success allowed to heal. The risk of infection of a new device or new lead rates and decreased potential morbidity compared to an placement at the time of explantation is too high and should not abdominal approach. be pursued. The proper management is the explantation of all prosthetic material, treatment of the infection, and repeat test SASP 2023 Question 34. stimulation in the future when the patient is completely A 61-year-old man with Parkinson's disease has urinary recovered. frequency, urgency, urinary incontinence, and weak stream. UDS reveals detrusor overactivity, a sustained voiding SASP 2023 Question 32. detrusor pressure of 88 cm H20, and a maximum flow of 7 An 85-year-old woman in an assisted living facility with a mL/sec. Cystometric bladder capacity is 275 mL. PVR is 150 history of asymptomatic bacteriuria has two days of urinary mL. The next step is: frequency, urgency, and incontinence. A urine culture reveals A. antimuscarinic. > 100,000 CFU/mL pan-sensitive E. coli. The next step is: B. baclofen. A. observation. C. alpha-blocker. B. cystoscopy and renal ultrasound. D. CIC. C. single dose antibiotic therapy. E. laser vaporization of prostate. D. antibiotic therapy for three to seven days. E. topical vaginal estrogen. ANSWER=C The UDS findings are consistent with involuntary detrusor ANSWER=D contractions and bladder outlet obstruction, most likely due to New onset symptoms in a geriatric patient with previously BPH. The most reasonable pharmacologic approach is to use an diagnosed asymptomatic bacteriuria warrants therapy. Generally, alpha-sympathetic blocking agent. Detrusor-external sphincter three to seven days of therapy is suggested. Good options include dyssynergia is not seen in Parkinson's disease. Thus, baclofen, five days of nitrofurantoin, three days of which is intended to induce skeletal muscle relaxation, is not trimethoprim/sulfamethoxazole (if resistance is 20% among E. indicated. Antimuscarinics may reduce involuntary detrusor coli strains locally), or seven days of beta-lactam agents as a contractions but may exacerbate emptying failure, so should not secondary option. Fluoroquinolones have a higher risk of adverse be used until his emptying improves. A trial of alpha-blocker is 8|Page warranted prior to initiation of CIC or a surgical debulking sling was placed, she will likely need to have the sling incised procedure. Incontinence rates are higher in patients undergoing regardless of UDS findings. Given the urinalysis findings, TURP with multisystem atrophy; however, this does not appear cystoscopy should be done to evaluate for urethral injury/erosion to be the case for patients with Parkinson's disease and bladder prior to the sling incision procedure. Sling excision would be outlet obstruction. necessary if urethral erosion is identified; however, it is usually not necessary for sling release and may result in a greater risk of SASP 2023 Question 35. recurrent stress incontinence compared to sling incision alone. A 32-year-old man being evaluated for infertility has a history Tamsulosin may help mild functional obstruction symptoms. of bronchitis and sinusitis. His semen analysis reveals a However, since her iatrogenic anatomic obstruction is unlikely to volume of 3.3 mL (normal > 1.5 mL), a sperm concentration improve, and given the relationship of symptoms to the sling of 34 million sperm/mL (normal > 15 million sperm/mL), and procedure, one must address the role of the sling in her voiding motility of 0%. The next step is dysfunction. A. serum FSH and testosterone. B. testing for cystic fibrosis mutations, SASP 2023 Question 37. C. sperm viability testing. The enzyme bound by tadalafil which causes lower back pain D. TRUS. in some patients is: E. adoption. A phosphodiesterase type 4. B. phosphodiesterase type 5. ANSWER=C C. phosphodiesterase type 6. Three male infertility conditions are associated with chronic D. phosphodiesterase type 8. upper respiratory infections: congenital bilateral absence of the E. phosphodiesterase type 11. vas deferens (CBAVD) associated with cystic fibrosis gene mutations, immotile cilia syndrome, and Young's syndrome ANSWER=E associated with inspissated secretions in the epididymis and vas All current phosphodiesterase-5 inhibitors have some cross- deferens. Patients with either CBAVD or Young's syndrome are reactivity to other phosphodiesterases. Phosphodiesterase-6 is azoospermic. Primary ciliary dyskinesia (also called immotile present in the retina, and its inhibition can lead to visual cilia syndrome) is associated with normal sperm concentrations disturbances, including how color is perceived (ie., blue-green but no motility or severely low sperm motility due to color changes). Both sildenafil and vardenafil are known to bind ultrastructural defects in the sperm tail. Primary ciliary dyskinesia phosphodiesterase-6 with greater affinity than tadalafil or associated with situs inversus is known as Kartagener's avanafil. Phosphodiesterase-11 inhibition is responsible for lower syndrome. Sperm with absent motility due to ultrastructural back myalgias and is impacted more heavily by tadalafil. From a defects are typically alive (viable), while most other causes of low clinical standpoint, patients who experience bothersome adverse motility are associated with non-viable sperm. Sperm viability effects from one agent (ie, blue-green color changes or testing will demonstrate a high percentage of viable sperm in backaches) may be changed to an alternative agent. primary ciliary dyskinesia. Partial ejaculatory duct obstruction Phosphodiesterase 4 and 8 have not been associated with may be associated with low sperm motility and low viability. bothersome adverse effects with sildenafil, vardenafil, tadalafil, Since TRUS is an invasive test, sperm viability testing should be or avanafil performed first. Genital tract infections may cause impairment of sperm motility but are usually associated with pyospermia and SASP 2023 Question 38. low sperm viability. Semen cultures may be considered in cases The most appropriate peri-operative management of a of pyospermia. Deficiency in FSH and/or testosterone would be patient undergoing adrenalectomy for Cushing's syndrome associated with decreased sperm concentration, not an isolated is: motility defect. While adoption may be an option, sperm viability A. hydration, alpha-blockers, and stress-dose steroids. testing would be the next step prior to recommending this. B. beta-blockers, stress-dose steroids, and careful glycemic control. SASP 2023 Question 36. potassium-sparing diuretics and stress-dose steroids. Eight weeks following placement of a midurethral sling, a 73- D. stress-dose steroids and careful glycemic control. year-old woman has difficulty voiding without leakage. Her E potassium-sparing diuretics, stress-dose steroids, and careful urinalysis shows large numbers of RBCs and WBCs, and glycemic control. PVR is 300 mL. The next step is CIC and A. UDS. ANSWER=D B.sling excision. Patients undergoing adrenalectomy for Cushing's syndrome have C. tamsulosin. an excess of corticosteroids from an adrenal adenoma or D. cystoscopy. carcinoma. These patients need stress-dose steroids and careful E sling incision. glycemic control as they often have obesity and diabetes. Alpha- blockers and hydration are indicated peri-operatively for patients ANSWER=D with pheochromocytoma. Beta-blockers may also be necessary The patient appears to be obstructed following midurethral sling pre-operatively for patients with pheochromocytoma if they are placement and should be considered for sling incision. UDS data tachycardic after alpha-blockade. Potassium-sparing diuretics are can be useful in some cases, but if the symptoms began after the important for the peri-operative management of patients with 9|Page hyperaldosteronism (Conn's disease) as they often have significant hypokalemia. SASP 2023 Question 38. The most appropriate peri-operative management of a patient undergoing adrenalectomy for Cushing's syndrome is: A. hydration, alpha-blockers, and stress-dose steroids. B. beta-blockers, stress-dose steroids, and careful glycemic control. potassium-sparing diuretics and stress-dose steroids. A 20 Gy XRT. D. stress-dose steroids and careful glycemic control. B. 30 Gy XRT. E potassium-sparing diuretics, stress-dose steroids, and careful C. single dose carboplatin. glycemic control. D. three cycles of BEP. ANSWER=D E. modified template RPLND. Patients undergoing adrenalectomy for Cushing's syndrome have ANSWER=B an excess of corticosteroids from an adrenal adenoma or The CT scan shows a 1.5 cm node in the interaortocaval region, carcinoma. These patients need stress-dose steroids and careful the primary landing zone for a right testis tumor. Thus, the patient glycemic control as they often have obesity and diabetes. Alpha- blockers and hydration are indicated peri-operatively for patients has a pT1bN1M0 or stage 2A seminoma. The treatment for stage with pheochromocytoma. Beta-blockers may also be necessary 12A seminoma is either 3 cycles of BEP, 4 cycles of EP, 30-36 Gy of external beam XRT to the para-aortic area and ipsilateral pre-operatively for patients with pheochromocytoma if they are pelvic lymph nodes, or potentially bilateral RPLND based on tachycardic after alpha-blockade. Potassium-sparing diuretics are recent preliminary data. Most patients with 2A seminoma get important for the peri-operative management of patients with hyperaldosteronism (Conn's disease) as they often have treated with XRT. Some patients do get chemotherapy, however, significant hypokalemia. as this patient has CKD, he is not a good candidate for platinum- based chemotherapy. XRT would be the recommended therapy. In the presence of visible retroperitoneal disease, 30-36 Gy is SASP 2023 Question 39. recommended (typically 30 Gy for 2A and 36 Gy for 28), to the The lithotriptor generator with the largest focal zone is: interaortocaval region and right iliac lymph nodes. If he was A. electrohydraulic. B. piezoelectric. undergoing adjuvant XRT for stage 1 seminoma, 20 Gy to only C. electromagnetic. the interaortocaval region would be sufficient. Based on the SEMS trial (which will be published in 2022), RPLND is a D. microexplosive. reasonable option for low-volume retroperitoneal seminoma and E. electroconductive. is associated with -85% three-year disease-free survival. However, it would be a bilateral RPLND, particularly with visible ANSWER=A Ease of targeting with large focal zone lithotriptors may lead to interaortocaval disease, and not a modified template. Single-dose improved efficacy with higher stone-free rates. Electrohydraulic, carboplatin is an option for the adjuvant treatment of stage 1 seminoma, but not for stage 2A or higher disease. or spark gap lithotriptors, like the original HM3, have the largest focal zones, which is likely the reason for their widespread SASP 2023 Question 41. acceptance. Piezoelectric devices have small focal zones with wide apertures of entry, thus minimizing patient discomfort but The maximum yearly whole-body exposure to radiation often have lower stone-free rates. Electromagnetic machines have recommended by the National Council on Radiation smaller focal zones but typically achieve higher pressures. Micro Protection and Measurements is: A. 1 rem. explosive lithotriptors are not currently used due to the B. 5 rem. requirement for lead azide pellets, and electroconductive C. 10 rem. machines are currently not utilized but retained smaller focal zones. D. 50 rem. E. 100 rem. SASP 2023 Question 40. ANSWER=B A 62-year-old man undergoes a right radical orchiectomy for Urologists may have significant occupational radiation exposure. a pT1b seminoma. Tumor markers are normal. Abdominal It is important to wear radiation protection for the body, thyroid, CT scan is shown and chest CT scan is normal. Serum creatinine is 1.9 mg/dL. The next step is: and eyes. Place the fluoroscopy beam under the table if possible and use the principle ALARA or "as low as reasonably achievable." The maximum yearly dose recommended by the National Council on Radiation Protection and Measurements is 5,000 mrem or 5 rem to the entire body, likewise, 0.5 rem is the maximum recommended dose to a fetus, and 50 rem is the maximum recommended dose to an individual body organ. 10 | P a g e  bowel integrity, neobladder reconstruction has been performed successfully. CIS in the bladder, tumor at the bladder neck, and SASP 2023 Question 42. positive pelvic lymph nodes are not contraindications for The nerves at the mid-portion of the clitoral body are found: orthotopic diversion. A ventrally. B. dorsally. SASP 2023 Question 45 C. laterally. A 50-year-old man with multiple endocrine neoplasia type 2 D. between the urethra and vagina. has hypertension resistant to three medications. MRI scan E. between the shafts of the corpora cavernosa. shows a 3 cm adrenal mass and plasma-free metanephrines are elevated. He is placed on maximal dose ANSWER=B phenoxybenzamine but has persistent episodic hypertensive The clitoral neural anatomy is similar to that of the normal male crises. The next step is: phallus. At the mid-portion of the clitoral body, the main nerve A. switch phenoxybenzamine to metyrapone. bundles are found dorsally. While individual nerve fibers are B. addition of prazosin. found circumferentially around the corpora, the main bundles are C. addition of metyrosine. not present ventrally, laterally, between the urethra and vagina, D. addition of clonidine. nor between the corpora themselves. Thus, the dorsal aspect of E. adrenalectomy. the clitoral shaft is the area that must be approached with great care if gender affirming surgery is performed to ensure future ANSWER=C genital sensation. In patients with a suspected pheochromocytoma, it is critical to achieve adequate alpha-blockade prior to surgery. This is SASP 2023 Question 43. typically accomplished with phenoxybenzamine. In patients in A 16-year-old girl has amenorrhea. The karyotype is 46,XY whom blockade with phenoxybenzamine is inadequate, the and serum testosterone is elevated. Her pelvic examination addition of metyrosine, a tyrosine hydroxylase inhibitor, has been will reveal a(n): recommended to prepare the patient for anesthesia or surgery. An A short vagina. alternative to metyrosine would be to continue the B.. imperforate hymen. phenoxybenzamine and add a beta-blocker, but in this setting of C. Uterine duplication. inadequate alpha- blockade, the addition of a beta-blocker has on D. vaginal septum occasion been found to be associated with increased alpha- E. bifid clitoris receptor stimulation and furthering hypertension. Therefore, the addition of metyrosine would be a better choice in patients who ANSWER=A have their hypertension poorly controlled by phenoxybenzamine. This presentation is most consistent with a female with androgen Weak alpha-blockers, such as prazosin, have been used; however, insensitivity syndrome (AIS) based on amenorrhea, karyotype, a majority of patients still appear to have hypertensive crises prior and elevated testosterone (indicating the presence of functional to or during surgery while on these drugs. Adrenalectomy would testicular tissue). The pelvic examination will most likely reveal be dangerous without pre-surgical medical stabilization which a short vagina, due to the effect of Müllerian inhibiting substance, has not been accomplished in this patient. Clonidine and causing the regression of the uterus, fallopian tubes, and upper metyrapone do not play a role in the medical management of vagina, but not uterine duplication. Imperforate hymen and pheochromocytoma. transverse vaginal septum can cause amenorrhea but are not associated with an abnormal karyotype. Bifid clitoris is SASP 2023 Question 46 associated with bladder exstrophy. Pathologic, as opposed to physiologic, post-obstructive diuresis results from: A. impaired concentrating ability. SASP 2023 Question 44 B. increased urea and sodium excretion. A 54-year-old man with clinical T2 bladder cancer is planning C. increased free water clearance. to undergo a radical cystectomy. A contraindication for D. decreased prostaglandin excretion. orthotopic diversion is E. decreased angiotensin II secretion. A. diffuse bladder CIS. B. Crohn's disease. ANSWER=A C. prior pelvic XRT. Physiologic post-obstructive diuresis is caused by retained urea, D. positive pelvic lymph nodes. sodium, and water. This can typically be observed by allowing E. tumor at the bladder neck. patients free access to drink as they become thirsty. Pathologic post-obstructive diuresis is caused by impairment of ANSWER=B concentrating ability or sodium reabsorption and frequently Absolute contraindications to the use of ileum in urinary tract requires treatment such as LV. hydration. Free water clearance, continent/reservoir reconstruction include short bowel syndrome prostaglandin, and angiotensin II secretion or excretion are not and small bowel inflammatory diseases such as Crohn's disease. related to pathologic post-obstructive diuresis. Prior pelvic XRT increases the risk of incontinence and complications, but with astute intraoperative assessment of the 11 | P a g e SASP 2023 Question 47 A. observation. A 72-year-old woman with pseudomembranous colitis is B. urine calcium creatinine ratio. treated with oral vancomycin. After 48 hours, her diarrhea C. non-contrast CT scan. worsens, and she develops fever and leukocytosis. The next D. VCUG step is: E cystoscopy. A. oral metronidazole. B. IV. vancomycin. ANSWER=A C. I.V. metronidazole. Benign urethrorrhagia is a common cause of pediatric gross D. LV. fluoroquinolone. hematuria in pre-pubertal and adolescent boys. Drops of blood E. surgical consultation. after voiding clear urine or blood spotting in the underwear suggest urethral bleeding. Pediatric urethrorrhagia is almost ANSWER=E always benign and self-limited. Renal/bladder ultrasound, non- The incidence of Clostridium difficile infection (CDI) is invasive uroflowmetry, and PVR can be considered as part of the increasing with a preponderance of the NAP1 hypervirulent strain workup but are usually normal. Additional upper tract imaging of C. difficile found in recent epidemics. It is believed the NAP1 with ionizing radiation is not necessary. Urine calcium:creatinine strain arose due to the widespread use of fluoroquinolone ratio can be part of the work-up of pediatric gross hematuria but antibiotics. The NAP1 strain is more likely to cause severe and is not warranted given the terminal nature of the hematuria. fulminant colitis, characterized by marked leukocytosis, renal Urethral strictures are not uncommonly diagnosed in patients failure, hemodynamic instability, and toxic megacolon. While who originally presented with urethrorrhagia. Because urethral oral vancomycin and oral metronidazole are both considered instrumentation may exacerbate existing urethral inflammation, standard therapies for CDI, recent studies suggest that neither cystoscopy nor VCUG should be considered in this vancomycin is more effective. Neither I.V. vancomycin nor I.V. otherwise asymptomatic child. metronidazole have been found to be more effective than the oral form of the medications for treatment of CDI. There is no role for SASP 2023 Question 50. fluoroquinolone antibiotics in treatment of CDL. This patient After enucleation of the entire adenoma during a holmium with worsening diarrhea, fever, and leukocytosis, is failing to laser enucleation of the prostate, a large capsular perforation improve with standard treatment, and thus surgical consultation with extraperitoneal extravasation of a moderate amount of is indicated. Subtotal colectomy with end ileostomy is the fluid is noted. The next step is: procedure of choice for fulminant CDI colitis non-responsive to A insert urethral catheter and return three days later to complete medications and has been documented to result in improved morcellation. survival. B. complete morcellation and insert urethral catheter for 24 hours. C. complete morcellation and insert urethral catheter for three SASP 2023 Question 48 days. Compared to placebo, monotherapy with Serenoa repens D. use alternate lobe fragmentation "mushroom technique." (saw palmetto) for men with bothersome LUTS due to BPH E open exploration is likely to result in: A. improved IPSS. ANSWER=C B. improved maximal flow rate. Most patients can be discharged home on the first postoperative C. decreased prostate size. day after holmium laser enucleation of the prostate (HOLEP). If D. lowered risk of acute urinary retention. there is no evidence of a definitive capsular perforation, the E. similar rate of adverse events. catheter can be removed the next day. In case of a large perforation, the catheter should be left for a few days. Only large ANSWER=E extraperitoneal or intraperitoneal bladder injuries during The use of over-the-counter phytotherapy continues to be a morcellation, or evidence of a large degree of irrigant popular therapy for the treatment of male LUTS due to BPH. extravasation from an extraperitoneal injury, require open However, there are a limited number of well-done placebo- exploration. If hemodynamically stable, there is no need to abort controlled trials evaluating its efficacy. The vast majority of these the procedure and subject the patient to another procedure for trials suggest that Serenoa repens is no more effective than morcellation. The "mushroom technique" is an alternate approach placebo. No differences are seen in regard to IPSS or flow rates. for adenoma removal, during which the lobes are left attached to There does not appear to be any decrease in prostate size or a stalk and later resected down to pieces that are suitable for evidence that suggests that this drug is able to minimize the risk coming through the resectoscope. In this case, the adenoma has of progression to acute urinary retention. Initial prostate size does already been entirely enucleated in preparation for using the not appear to impact the outcome when Serenoa repens is used. morcellator. Adverse events are mild and appear to be comparable to a placebo. SASP 2023 Question 51. A 35-year-old healthy woman has a left ureteroscopic SASP 2023 Question 49. intervention for a 1.9 cm upper pole renal stone. One week A 12-year-old boy has painless terminal gross hematuria. after stent removal, she has mild left flank pain. Low dose CT Physical examination is normal. Urinalysis shows 3-5 scan images are shown. The next step is: RBC/hpf. Urine culture is negative. The next step is 12 | P a g e  D. baclofen. E. UDS. ANSWER=B UTI in patients with spinal cord injury on CIC is commonly seen but can be a challenge to diagnose. Almost all urine collections will show bacteriuria, and pyuria may occur solely due to the irritative effects of catheterizations, and may not always be related to the presence of infection. The usual symptoms of UTI A. observation and serial imaging. such as urinary frequency, urgency, and dysuria will not be noted B. SWL of lead fragment. in patients with a complete neurologic injury who have no C. ureteral stent placement. bladder sensation. Typical UTI symptoms in a patient with a D. nephrostomy tube placement. spinal cord injury may include urinary incontinence between ureteroscopy with laser lithotripsy, catheterizations, increased spasticity (as seen in this patient), malaise, lethargy, persistent cloudy or malodorous urine, and ANSWER=A discomfort at the level of the flank, back, or abdomen. Bacteria This patient has a steinstrasse and mild ureteral stone symptoms. levels are problematic to interpret and are classically only treated Patients with minimal symptoms, adequate renal function, and no if they are greater than or equal to 100 cfu/ml and the patient is signs of sepsis can be managed conservatively, and symptomatic. Due to the symptomatic complaint of increased approximately 50-60% will resolve spontaneously. These spasticity and positive urine culture, this patient should be given patients must be monitored closely with imaging to ensure antibiotics. If the spasticity is not resolved after treatment, the intervention is not needed. Patients with persistent steinstrasse patient should be carefully examined for any physical injury will require intervention and/or decompression. Placement of a below the level of his lesion, such as obstipation, decubitus ulcer, PCNT or ureteral stent would then be options, especially in the ingrown toenail, developing syrinx, etc. Baclofen is a commonly setting of infection. SWL of the lead fragment, especially if a used treatment for spasticity in spinal cord injury (SCI) patients large lead fragment is present, can sometimes be successful as and should be considered for use if the spasticity is not resolved well. If intervention is required, ureteroscopy is the definitive after treatment of the UTI, and additional patient evaluation fails treatment with success rates approaching 100%. to reveal an underlying cause. Elevated storage pressures do place a patient at increased risk of symptomatic UTI, and UDS should SASP 2023 Question 52 be considered if this patient continues to experience recurrent A potential side effect of SSRIs for the treatment of symptomatic infections. premature ejaculation is: A insomnia. SASP 2023 Question 54. B. depression. A 53-year-old woman has POP-Q stage 3 prolapse and C. erectile dysfunction. urinary incontinence. No SUI is noted during UDS with cough D. decreased sweating. or Valsalva maneuver performed at a maximum bladder E. increased sexual desire. capacity of 400 mL with or without reduction of pelvic organ prolapse by physical manipulation. The next step is ANSWER=C A fill the bladder to 100 mL beyond maximal capacity and repeat The most common adverse effects of SSRIs are yawning, mild stress maneuvers. nausea, excessive sweating, fatigue, diarrhea, erectile B. repeat UDS with prolapse reduction performed by a vaginal dysfunction, and loss of libido. A sudden reduction or cessation pessary. of long-term treatment of SSRIs can lead to "SSRI C. remove urethral catheter and repeat stress maneuvers. discontinuation syndrome," which includes symptoms such as D. prolapse repair with no anti-incontinence procedure. nausea, vomiting, dizziness, headache, ataxia, drowsiness, E. prolapse repair with sling. anxiety, and insomnia. These symptoms begin one to three days after the drug cessation and may continue for more than a week ANSWER=C in some patients. The combination of more than one SSRI may The AUA/SUFU Urodynamics Guidelines suggest that clinicians lead to "serotonin syndrome," which can be life-threatening and should repeat stress testing with the urethral catheter removed in requires immediate cessation of one of the offending agents. patients suspected of having stress incontinence (SUI) who do not demonstrate SUI with the catheter in place. Filling the bladder to SASP 2023 Question 53. a higher volume than maximum capacity would not be indicated. A 24-year-old man with a T4 complete spinal cord injury who Changing the prolapse reduction method would not be expected manages his bladder with CIC every six hours complains of to change the findings. It should be noted the AUA Guidelines on increased lower extremity spasms during the past week. UDS assessment of stress incontinence state that there is no Urine culture reveals 1,000 cfu/mL of E. coli. He denies standardized method with which to reduce prolapse during UDS. urinary urgency or incontinence. The next step is: Patients with marked vaginal prolapse are at risk for de novo or A. observation. worsening stress incontinence after prolapse treatment, and the B. antibiotics. presence of a urethral catheter may prevent the demonstration of C. antibiotics if pyuria is present. stress incontinence during UDS due to obstruction. Removal of 13 | P a g e the catheter (with continued reduction of prolapse) allows for CT scan is normal. She is dry after placement of an indwelling complete evaluation and is the next step prior to proceeding with catheter. The next step is: surgical planning. A bilateral retrograde pyelograms. B.double dye test. SASP 2023 Question 55 C. continued catheter drainage. A 55-year-old man is diagnosed with Paget's disease of the D. transvaginal repair. glans penis. In addition to excision, he should undergo: E. transabdominal repair. A. HPV testing. B. HIV testing. ANSWER=C C. bone scan. A newly diagnosed fistula may heal spontaneously with D. T-cell lymphoma evaluation. placement of an indwelling catheter. Spontaneous healing of the E. cystourethroscopy. fistula is unlikely to occur if leakage still occurs with the catheter in place. Since the patient is dry with the catheter in place, ANSWER=E additional radiographic studies and evaluation with a tampon dye Extramammary Paget's disease (EPD) is an uncommon test are not needed. Repair would be considered if the fistula does intraepithelial adenocarcinoma of sites bearing apocrine glands not heal after two-three weeks of catheter drainage, which is often and can involve the penis and scrotum in males. The lesion in combined with antimuscarinic use. EPD is usually an erythematous plaque with a sharp border between normal and involved skin. It may be asymptomatic, SASP 2023 Question 58. pruritic, or associated with burning pain. Treatment generally A 26-year-old man with complete C7 spinal cord injury involves surgical excision or Mohs micrographic surgery. There managed by CIC has recurrent episodes of vague abdominal is an important association between EPD and another underlying pain, severe headache, and diaphoresis. Imaging reveals a 12 malignancy in 10% to 30% of cases. In males, associations mm obstructing radiolucent UPJ stone and urinalysis shows between EPD and urethral, bladder, and rectal cancers have been a pH of 5.0, 25-50 RBC/hpf, 0-5 WBC/hpf, and no bacteriuria. described. It is critical, therefore, to perform a systematic The next step is: evaluation for underlying carcinoma in cases of EPD, including A urinary alkalinization. evaluation for bladder and urethral carcinoma with B. urinary alkalinization and tamsulosin. cystourethroscopy. There is no known association of EPD with C. stent placement. HIV (as in the case of Kaposi sarcoma) or HPV (as in the case of D. SWL. verrucous carcinoma). Cutaneous T-cell lymphoma can occur in E PCNL the penis but would be diagnosed on the excisional biopsy and is not associated with EPD. Although Paget also described a disease ANSWER=C of the bone that bears his name, it has no relation to the EPD. The patient presented with symptoms of autonomic dysreflexia Thus, a bone scan is not warranted. that have temporarily subsided but are likely to recur. This represents a life-threatening situation. Stent placement will avert SASP 2023 Question 56 recurrent obstruction and dysreflexia. Urinary alkalinization is The imaging modality that most accurately predicts renal not appropriate since the patient is symptomatic. Medical functional recovery following reversal of prolonged expulsive therapy is not appropriate due to stone size and obstruction is a: location. SWL will not reliably relieve the acute obstruction and A renal ultrasound with Doppler. risk of autonomic dysreflexia, and therefore, should not be B. DMSA scan. considered a first-line treatment option. PCNL and primary C. DTPA scan. ureteroscopy with definitive stone treatment could each be D. MAG-3 scan. considered an appropriate treatment option if the patient is not E. CT urogram. infected and medically stable. ANSWER=B SASP 2023 Question 59. Cortical phase nuclear renography may offer an accurate A 32-year-old HIV-positive man has right epididymitis. The prediction of functional renal parenchymal recovery following next steps are Gram stain of urethral secretions or urine reversal of prolonged obstruction. DMSA is a cortical agent and PCR, empiric therapy, and: has been shown to be superior to the tubular agents, DTPA and A. syphilis serology. MAG-3 for the prediction of renal recovery. Estimation of renal B. hepatitis B serology. parenchymal thickness on CT scan remains investigational as a C. hepatitis C serology. means to evaluate existing renal function. Doppler ultrasound of D. percutaneous epididymal biopsy. the renal vessels is an assessment of renal arterial flow in patients E. culture of expressed prostatic secretions with kidney damage as a result of renal artery stenosis but cannot predict renal functional recovery. ANSWER=A Syphilis in the United States is a concern, especially among HIV SASP 2023 Question 57. patients. Approximately 29% of screened men with HIV have A 55-year-old woman has urinary incontinence two weeks positive syphilis serology. The incidence rate of syphilis in the after a vaginal hysterectomy. Cystoscopy confirms a VVF and HIV population is 77 times greater than that of the general 14 | P a g e population. All patients who test positive for primary or D. change to malleable prosthesis with incision and grafting. secondary syphilis should also be tested for HIV infection. The E. complete IPP placement and perform incision and grafting. U.S. Preventive Services Task Force (USPSTF) recommends that men at increased risk should be screened for HIV and syphilis. ANSWER=E Persons diagnosed with other sexually transmitted infections (ie, Penile curvatures greater than 60 degrees may limit or prevent chlamydia, gonorrhea, genital herpes simplex, human penetration, and therefore some form of intervention should be papillomavirus, and HIV) may be more likely than others to employed. It is unlikely that repeat modeling or changing the type engage in high-risk behavior, placing them at increased risk for of prosthesis to a two-piece or malleable device will significantly syphilis. Screening tests for syphilis include nontreponemal tests improve the curvature. Both a penile plication or an (VDRL or RPR) followed by confirmatory fluorescent incision/excision and grafting technique would be appropriate treponemal antibody absorbed (FTA-ABS) or T. pallidum choices in this setting with neither demonstrating clear particle agglutination (TP-PA). For epididymitis in sexually superiority. active men younger than 35 years, the CDC recommends: (1) urethral Gram stain, (2) urethral culture or nucleic acid SASP 2023 Question 62. amplification (PCR) test for N. gonorrhea and C. trachomatis. (3) A 55-year-old man with diabetes has scrotal pain. Physical examination of first-void uncentrifuged urine for leukocytes if the examination reveals scrotal edema and erythema, and he is urethral Gram stain is negative, and (4) syphilis serology and HIV afebrile. Scrotal ultrasound is shown. The next step is: counseling and testing. Empiric therapy with ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg orally twice a day for ten days is indicated before laboratory test results are available. Testing for hepatitis B and C, culture of the expressed prostatic secretions, and percutaneous epididymal biopsy are not recommended. Culture of expressed prostatic secretions is not recommended since the patient did not present with symptoms of prostatitis. SASP 2023 Question 60 A. NSAIDs. A 52-year-old asymptomatic man with an ileal conduit is B. antibiotics and scrotal support. newly diagnosed with a 1 cm stone within the conduit. His C. spermatocelectomy. renal ultrasound is normal. The next step is: D. incision and drainage. A observation and serial imaging. E. excision of involved skin and broad spectrum antibiotics. B. CT scan. C. loopogram. ANSWER=E D. endoscopy and basket removal of the stone. Necrotizing fasciitis often causes subcutaneous emphysema that E. laser lithotripsy. can be detected as crepitus on