143 Bladder disorders – How you’ll see them on your exam

Hello and welcome to the Physician Assistant Exam Review Podcast. Today’s a big day here. We’re beginning the blueprint from the beginning. We finished the entire thing for the second time through, and it gets to be more and more fun each time I go through it because I get better at teaching it. I get better at looking at the questions. I get better at looking at the information that’s coming to you, and through your feedback, everything gets refined. So initially, when I first did the very first pass, I thought, when I finished, what would I do?

And I found that going back through another time has been incredibly beneficial. So I’m excited that you’re here with us today. We’re going to be jumping in with genitourinary. My name is Brian Wallace. I’m the host and creator at Physician Assistant Exam Review. I’ve been behind this microphone for almost 15 years now. And what we’ve been doing is helping PAs, NP, medical students, and pharmacy students excel in school and actually start to enjoy their lives.

That’s really, really the goal. Isn’t just getting through school, but maintaining some level of happiness as you do it. We do that by covering medical content, of course, because that’s the building blocks, the foundation of what you need. But what I’ve found over the years is that’s not the biggest piece that’s missing. Most schools do a great job. Most PA programs do a great job. Most review books do a great job of covering medical content.

Where I find the gap to be, where I find the issue to be, is in how to cover it, how to remember it, how to retain it, how to have it available for you when your preceptors ask you questions, how to have it available for you when you’re on an exam, all of those things, and then how to prepare for your exams, specifically for medical exams, specifically for high-stakes exams, and then how to cover, how to show up as your best possible version of you, how to be the person who can return all the information, that they’ve learned. And we call that peak performance. And that includes managing anxiety, especially testing anxiety. But anxiety in all, you know, it kind of overlaps. The tools we use in one area work in other areas. So if it’s testing anxiety versus being nervous on rotations or in surgery or any of these things, it’s all going to be the same. It’s all going to help.

All right. We’re recording this on November 6, 2025, which also means that Thanksgiving’s right around the corner. We’re going to talk a lot about gratitude here because gratitude is a practice that is phenomenally powerful for dealing with anxiety. Phenomenally powerful. That’s not going to be the focus of today’s podcast. It’s not going to be our point for today. We’ll get to that as we get closer to Thanksgiving.

But I do want to mention what comes right after Thanksgiving, which is Black Friday. And I’m putting together a Black Friday special package for students to reboot their system. If you’re struggling, if you’re having trouble, if you’re falling behind, if you feel like everybody’s smarter than you, if you feel like you can’t keep up or that your grades aren’t what they should be, I’m putting together a package just for you. You’re going to love this. I don’t have all the details for you yet. The best way to get the details when they come out is to go to physicianassistantexamreview.com/daily. And I say daily because you’re going to get daily tips, techniques, philosophies, questions, all kinds of things are going to come your way once you sign up for the community.

But in addition to that, you’re also going to get the information about promotions I have coming out. So the Black Friday deal, the Black Friday package being one of those. So if that interests you, if you’re falling into that category, certainly head over there, physicianassistantexamreview.com/daily to make sure that you’re getting notified as soon as that Black Friday deal, the details come out. And then once it goes live.

All right. We’re beginning today with GU, beginning with bladder disorders and then congenital and acquired GU disorders. It’s kind of a weird structure in my head, but we’re going to follow the blueprint and that’s what we’re going to do. I also want to be really clear, as this is sort of a reboot, episode one in my head, that what we do here is different from what anyone else does. And I kind of already said this, but I want you to know that we’re not about content here at Physician Assistant Exam Review. We are not about content. And I say that, understand that content is the most important thing and say that knowing we’re going to cover content today.

But I want you to understand that there are other places you can get pure content. If you want someone to just recite a review book to you, there are tons of places to get that. Please go there. What we do here is review the content in a way that we can contextualize it for your test. We can contextualize it for your exams, for your studying, to make things better, to make them last longer. So you’ll hear us do things here a little bit different. We’re going to cover them a little bit differently.

I’m going to tell stories as we go through it about my experiences. Part of the reason for that is, if you don’t have your own stories for each of these, you need to borrow other people’s stories to hold on to them. We don’t remember facts and data and independent data points. We remember stories and pictures and images. That’s why I cover it the way I do. Everything we do in here is designed to help you retain more information. May not be your style, and that’s fine.

There are plenty of other places you can go for that, but I want you just to understand where I’m coming from and what I do. Speaking of which, we’re going to begin with the priming questions. And the priming questions are designed specifically to get you active and engaged right from the very beginning. Learning doesn’t happen by letting the material wash over you. Learning happens by you participating, by you reaching out and manipulating the information. That’s how strong neural networks get made. That’s how literally changes are made in your brain.

And there have been studies shown that despite getting wrong answers on questions, it builds a scaffolding out for you to hold on to the information. So, it doesn’t matter if you get them right or wrong. I know that’s something I always hear from students is the concern that they’re going to get something wrong or that they’re not going to know something and it’s going to remember it that way. It doesn’t work that way. Getting something wrong helps you to retain it longer. It makes it stick out in your head and helps you to retain it longer. So don’t worry about getting them wrong.

If you try, you will do better.

All right, let’s get started with our priming questions for GU. What type of urinary incontinence causes leakage with laughing or coughing? What type of urinary incontinence causes leaking with laughing or coughing? What type of urinary incontinence is caused by overactive detrusor contractions and urinary urgency? What type of urinary incontinence is caused by overactive detrusor contractions and urinary urgency? An infant’s testicle remains undescended at 6 months of age. What is the next step in management?

An infant’s testicle remains undescended at 6 months of age. What’s the next step in management? And don’t worry, I’m going to give you the answers at the end of this. But we’re going to get the answers as we go through them as well. A painful curved erection in a middle-aged man makes sexual intercourse difficult. What’s the diagnosis? Sorry, I struggle to read my own question.

Painful curved erections in a middle-aged man make sexual intercourse difficult. What’s the diagnosis? A child has recurrent febrile urinary tract infections and hydronephrosis is seen on ultrasound. A child has recurrent febrile urinary tract infections and hydronephrosis is seen on ultrasound. What condition do you suspect?

All right, I hope you gave those a try for the reasons we talked about, and we’re going to go ahead and get started with urinary incontinence. This is something that I actually really struggled with in PA school. I didn’t get it, and now I do a lot of urogyn surgery, and it makes a whole lot more sense, and it’s not nearly as difficult as I led myself to believe, as there are other topics like that for you, that you’re telling yourself are harder than they actually are. Urinary incontinence being one of those for me. This is involuntary loss of urine due to dysfunction of bladder storage, outlet control, or both. This is classified under a couple different things, right? So stress, urge, overflow, functional, or mixed.

This is most common in women after menopause or after childbirth or both. Overflow type occurs more often in men with benign prostatic hyperplasia or neurological diseases. We’ll talk about that as we go. Stress incontinence. This is a leakage with increased abdominal pressure. So stress incontinence is when someone has some leaking after coughing or sneezing. Exercise is one.

Laughing. And again, this is most common with postpartum or postmenopausal women. What I’m going to include here are the way the question stems will be worded for you, because again, I’m most concerned with how these are going to come to you while you’re sitting in your exam. So, a question stem for something like stress incontinence would be would be likely include a postmenopausal woman who reports urine leakage when she exercises, laughs, or coughs. Pretty straightforward stuff. Urge incontinence. This is a sudden strong urge to void with the inability to reach the toilet in time.

This is caused by an overactive detrusor muscle. Nocturia is common. Here the stem would describe a patient who feels an abrupt urge to urinate and can’t get to the bathroom, often awakening several times overnight. Overflow incontinence. This is a dribbling and incomplete emptying due to bladder outlet obstructions. This is an obstruction problem or a detrusor underactivity. So we’re not emptying the bladder is what’s happening here.

This is seen with benign prostatic hyperplasia or neurogenic bladder or in something like diabetes where you’re getting that neurogenic bladder right. The question stem here would likely describe an older man with a benign prostatic hyperplasia who reports dribbling urine and sensation of incomplete emptying. Functional incontinence is a normal bladder function but impaired mobility or cognition. So here you have a patient who is elderly, maybe a nursing home resident with dementia who’s unable to get to the bathroom before urinating. Everything is, it’s not really a GU problem, right? The bladder’s working, the detrusor muscles are working, there’s no stress incontinence, the urethra’s working. The problem is that they can’t get to the bathroom or they don’t realize they need to.

A mixed incontinence is a combination of stress and urge symptoms common in older women. Here again, we’d get an older woman with both leakage when coughing and episodes of urgency. Diagnostics, urinalysis, and urine culture can probably come first. We’re going to… Why? Because we want to rule out that urinary tract infection. We’re going to do a serum BUN and creatinine.

Again, we’re just going to assess renal function throughout here.

Now, you can use an ultrasound to determine post void residual measurements. So, you can ultrasound the bladder to get a volume after the patient urinates. So, less than 50 milliliters is normal. Greater than 200 milliliters still in the bladder after urination suggests an overflow incontinence. And suggests some kind of a problem there. In older adults, residual can be up to 100 milliliters and that can be normal. So you can do a bladder or a bladder stress test.

So what you do is you have a patient with a full bladder and you have them cough and this confirms the stress incontinence if they leak at that point. You can have a patient do a voiding diary 48 to 72 hours, and also a medication review because there are some medications that can cause issues here. Things like diuretics, anticholinergics, calcium channel blockers, opioids, and alpha blockers. But that voiding diary and the medication review is going to be helpful in determining if this is, again, a functional problem, what’s actually going on, and trying to put the pieces together. Urodynamic studies is a small catheter. This measures bladder pressure and urine flow during filling and emptying, and it’s used to identify detrusor overactivity, impaired contractility, or outlet obstruction when the diagnosis is uncertain. And then you’re going to want to do a neurological eval, so consider if diabetic neuropathy or spinal cord involvement is suspected, because there can be a host of reasons here, right?

So if we’re going to be addressing them, we need to know what they are. So step one is a standard behavioral and lifestyle measurements. We’re going to adjust what we’re doing. This is one of my biggest frustrations when I look at medicine. I don’t think we’re spending enough time in behavior and lifestyle, things that we can actually do to affect our own health. Bladder training is going to be on the list here. So scheduled voiding at gradually longer and longer intervals to increase bladder capacity and reduce urgency episodes.

Timed voiding, fluid management, limiting caffeine, limiting alcohol, right? So, timed voiding would be like making sure, and fluid management would be, if you’re having trouble waking up overnight, perhaps you stop drinking by three or four o’clock in the afternoon or five o’clock in the afternoon. And you set up voiding times whether you need to go or not in order to manage that frequency. On pelvic floor exercise, Kegels can help for stress incontinence. Weight loss and smoking cessation can help. Topical vaginal estrogens for postmenopausal women, if they have atrophic urethritis or vaginitis, this can help. I guess that would probably be under pharmacological though, not lifestyle.

So maybe we’ll move that down. Step two, pharmacological treatment. This goes along with the type of issue that the patient is having, right? So we’re going to talk about these independently. Urge or overactive bladder. Here, you’re going to use something like an anti-muscarinic agent. So oxybutynin, tolterodine.

Other names I can’t pronounce, and hopefully you can do it better than I can. These reduce detrusor contractions. You’re going to want to avoid these in gastric retention or untreated narrow-angle glaucoma patients. That’s just something to add, but I don’t think you’re really going to need that. You know what? Let me just go ahead and take that out of my notes because I don’t think it’s going to be as relevant to you. Beta-3 adrenergic agonists may be something else you can do.

This relaxes bladder muscles. That’s going to be for urge or overactive bladder. Overflow incontinence. Here, you’re going to use an alpha adrenergic blocker. So, tamsulosin, terazosin, these relieve obstruction in benign prostatic hyperplasia. Right, so those are going to be, those alpha adrenergics are going to be to help with the benign prostatic hyperplasia, right? Intermittent self-catheterization may be needed in overflow incontinence.

Remember, overflow incontinence, they don’t get a complete emptying, so that’s where the problem builds up. They’re carrying 200 or more milliliters of urine after urinating, so they may need intermittent self-catheterization. I know that doesn’t sound pleasant, but that’s going to be an option. For stress incontinence, here you can do pelvic floor therapy. That’s going to be first line. You can do pseudoephedrine, which is an alpha agonist, which may increase urethral tone. You can use a pessary to help hold up a pelvic organ prolapse if that’s a contributing factor.

And then for functional incontinence, this is going to be more, and I can see where I put the wrong part in my notes here. Again, functional incontinence, this should be under behavioral modifications. You’re going to modify the environment. You’re going to move things around to make it easier to get to the bathroom for this individual. You’re going to schedule, again, voiding time to make it so that this person’s going whether they need to or not. And you’re going to make sure they have a clear path and easy access to the restroom. Surgical and procedural options.

For stress incontinence, you can do a mid-urethral sling or urethropexy for refractory cases. So, we do this all the time and put a sling in that helps to be used as a backstop for your urethra. So, the urethra gets too laxed and it needs something to be able to… to need some support. And that’s what that sling… we surgically go in and insert it and that helps with that. Overflow incontinence.

This is that outlet obstruction, right? So, if this is an issue with benign prostatic hyperplasia, we can go in and remove the prostate. For refractory urge or overactive bladder, the surgeon I work with also will do nerve stimulators, which is a sacral neuromodulation that they can use. You can also use a few other things, but you can sort of stimulate the bladder in certain ways to make it more or less active. A new section I want to add to this was exam keys. So, ways that you’re going to see this stuff on the test. So, for leakage with coughing and sneezing, that’s going to be stress incontinence.

And here you’re going to use pelvic floor therapy and a sling procedure if you need to. Sudden urge and nocturia would be urge incontinence. Here you’re going to use oxybutynin or bladder training. Dribbling, weak stream, high post-void residual, benign prostatic hyperplasia, this is going to be overflow incontinence. This is going to be tamsulosin or intermittent catheterization, and then a TURP if obstruction persists or removal of the prostate. Incontinence and dementia or immobility. So if you see that in a question, it’s going to be functional incontinence.

You’re going to schedule going to the bathroom and make sure they have a clear path and assistance.

All right, overactive bladder. Urgency, frequency, nocturia with or without urge incontinence. This is the key. So it’s similar to urge incontinence, but you can have urgency, frequency, and nocturia without urge incontinence. So it’s a little bit more of a global picture. This is in the absence of infection or other identifiable cause. That’s really, really important.

This is caused by detrusor muscle overactivity, leading to involuntary bladder contractions and reduced control. This is common in older adults. Clinical presentation. Urinary urgency, frequent small volume voids. So like they’re going to the bathroom seven or eight times per day and you obviously get nocturia with that. They may have urge incontinence, but it may not be part of the system, right? No dysuria, no hematuria, no fevers.

So there’s no infection. That’s important to remember. The question stem here is definitely going to be like an older adult who reports a sudden strong urge to urinate and frequently voids these small amounts during the day and overnight. Diagnostics, you’re going to want to rule out a urinary tract infection. So very similar to what we just finished talking about, post-void volumes less than 50 or less than 100. Voiding diary, we’re going to be doing that. We’re going to be reviewing their medications.

We’re going to do urodynamic studies. We’re going to do a cystoscopy perhaps to consider, but only if there’s something like hematuria or pelvic pain or something else to make me worried about this patient. I’m not going to jump to a cystoscopy, but it’s on the list of things we can use. What’s a cystoscopy? A cystoscopy is when we take a scope and put it up through the urethra and look into the bladder to actually visualize if there’s any kind of issues. Treatment. Again, we’re going to start with behavioral and lifestyle issues.

So bladder training, like we just got done talking about. Timed voiding, gradually increasing the intervals of time between voids. Kegel exercises may be helpful to limit caffeine, alcohol, and other things that might cause you to have to urinate. Weight reduction. Constipation management can be a good one. So pharmacological management here is again going to be antimuscarinics, oxybutynin, tolterodine. I’m going to stop naming them because I can’t pronounce them.

You can check the notes at physicianassistantexamreview.com/143. You’re going to want to avoid these in glaucoma patients. Something to note. You can also use beta-3 agonists. These relax the bladder muscles if the antimuscarinics are not tolerated well. Again, you can do the nerve stimulators. So you can do it.

There’s a non-invasive posterior tibial nerve stimulation, or you can actually implant a sacral neuromodulation device that will assist with this. You can also use botulinum toxin and inject it into the detrusor muscle to help with those contractions. And then the effects last like six to nine months, just like Botox. For overactive bladder, our exam keys are going to be things like urgency, frequency, nocturia without infection. We’re going to think overactive bladder first. You can do bladder training and Kegel exercises as the first line. From there, we’re going to do add oxybutynin or tolterodine.

We can do nerve stimulation. I don’t think you’re going to get that far along in your PANCE. It seems really further than I would think they would go. The next one on our list is bladder prolapse. So this is what we call a cystocele. Prolapse is just when an organ basically penetrates out into an area it’s not supposed to be in. So here in this case, the bladder descends into the anterior vaginal wall due to weakened pelvic floor or loss of connective tissue support.

So this usually happens in, again, in patients who are postmenopausal, in women who have had children. So you’ve had loss of some of the support structures in there to begin with. And then the bladder descends into the anterior wall of the vagina. Obviously, this goes up with multiple vaginal deliveries. Clinical presentation here is the patient might feel a bulge or pelvic pressure or heaviness that’s worse with standing or straining. They may have urinary frequency, incomplete emptying, or stress incontinence.

Now, you can get an obstructive issue here where they don’t get complete emptying because if the bladder has descended into the anterior vaginal wall, then it’s in a more difficult space when it’s trying to void. It actually has to kind of push uphill a little bit to empty the bladder, so it’s a little bit more difficult. So you can get some of that obstructive overflow. Exam shows anterior vaginal wall protrusion, and this is accentuated with a Valsalva maneuver. This question stem would likely describe a postmenopausal woman with a vaginal bulge and urine leakage when coughing or standing, and it’s relieved when lying down. So this goes kind of hand in hand with stress incontinence. They’re not the same, but they’re very similar.

What we’ve done is made it so that the structures in this area have been weakened, and we’re not working as well as they should be. So the symptoms will be the same, but it’ll be maybe for slightly different reasons. Here you’re going to do a pelvic exam. This is going to confirm your diagnosis where you can actually feel that bulge in the anterior vaginal wall, and you can feel it more when the patient Valsalvas. You can get that, like I said, for your diagnostics. You can get an increase, that incomplete emptying of the bladder because of the relative position of the bladder to the urethra during voiding. Urinalysis, you want to maybe rule out a UTI, and you really don’t need imaging for this.

Treatment. So, for minor cases, or very mild, pelvic floor Kegel exercises will be helpful. Topical vaginal estrogen or a pessary for support can be helpful, but a lot of times it’s past that point by the patient, by the time the patient is complaining. So a surgical repair with an anterior colporrhaphy, which is a bladder suspension. See that I could pronounce correctly. I can’t do the medications, but the procedures I can do. You might want to have these patients avoid heavy lifting, managing chronic coughs and constipation can be helpful, that type of thing.

But the surgical correction is the answer. And again, I work with an amazing urogynecologist, and we do a ton of these procedures and help a lot of people.

Exam keys, urinary symptoms plus anterior vaginal wall protrusion, you’re thinking bladder prolapse. So those urinary symptoms alone, you’re thinking stress incontinence. With that anterior vaginal wall protrusion, you’re thinking bladder prolapse. You’re thinking a cystocele. So that’ll be the difference. So it’s a cystocele with stress incontinence. First line, again, is going to be Kegel exercises, definitive diagnosis is that, I’m sorry, definitive treatment is the anterior colporrhaphy.

That ends the section on bladder disorders. We’re going to move into congenital issues and traumatic issues or acquired abnormalities of the GU system.

So let’s start with the congenital ones, which is going to start with cryptorchidism. Cryptorchidism is one or both testes absent from the scrotum due to failure of descent. This is the most common congenital GU abnormality, and it’s usually unilateral. The problem here is you can get an increased risk of infertility, testicular torsion, and malignancy. Risk factors here include premature birth, low birth weight, family history of undescended testes. That’s actually one I might hold on to, the family history part. That might be helpful in your questions.

Clinical presentation found on routine peds exam as an empty or undeveloped hemiscrotum. So this is something you’re checking for during your peds exam. Testes may be non-palpable or located in the inguinal canal or abdomen. The question stem here is likely to describe an infant boy with one side of the scrotum empty on physical exam. Makes sense, right? That’s how you’ll probably see that. Six-month-old, four-month-old, eight-month-old with a non-palpable, with only one palpable testes.

Diagnostics, again, physical exam. Ultrasound, you can use if you can’t feel that testes on exam, then yeah an ultrasound might be a good way to look for it. If the ultrasound is inconclusive, you can get an MRI. The one thing you’re going to want to watch out for is to differentiate from retracted testes, so the testicle not just retracted up into the body a little bit, but actually not descended. Treatment, initially watchful waiting. Most testes descend between six and twelve months of age. If persistent after six months, definitely by a year, you’re going to want to do an orchiopexy.

HCG injections may stimulate testosterone and descent, but are less reliable.

Exam keys here. It’s an infant with an empty scrotum on one side, right? You’re going to observe that until six months and then look for your orchiopexy. Increased risk of testicular torsion. Our next one is Peyronie’s disease or Peyronie disease. I always thought it was an apostrophe S, but maybe I’m wrong. This is a fibrous scar tissue formation within the tunica albuginea of the penis causing a curvature or deformity during erection.

This may lead to painful erections and difficulty with intercourse. So remember we talked about that in our priming questions. Here’s your answer. It’s thought to have happened due to microvascular trauma. Clinical presentation is a curved or bent penis during erection. Pain and discomfort with erection. So our question stem here is going to be a middle-aged man with progressive penile curvature and painful erections that interfere with sexual activity.

It should be pretty straightforward. Diagnostics is really just a clinical exam and history. You can do an ultrasound to look for the extent of those fibrous plaques buildup. The treatment is going to be as mild as observation because it can resolve. Otherwise, you’re going to do intralesional injections. Things like verapamil or corticosteroids may reduce plaque. And then you can actually surgically go in and remove some of that plaque.

I don’t know anything about doing that, but that’s what the books say. Genitourinary trauma. That’s our next section here. And this is always a little weird, right? When the when the blueprint’s like, genitourinary trauma, and you’re like, okay, what does that mean? What am I going to cover? So I went through some material and I came up with a list that I like, that I think will work, but there’s no clear definitions here, right?

It’s kind of your own judgment a little bit, what your school thinks. For me, this is an injury to the kidneys, ureters, bladder, or urethra from blunt or penetrating trauma. This is often associated with pelvic fractures, motor vehicle accidents, or straddle injuries. You want to be looking for hematuria, urinary retention, or flank or perineal bruising. That’s kind of the overall thing that I was sort of searching for. Renal trauma. So I broke these down into renal, bladder, urethral, penile, and we went from there.

So for renal trauma, you can get flank pain, right? You’re going to be pain in the flanks makes sense. Ecchymosis or gross or microscopic hematuria after a blunt injury. That tends to be the most common thing. For a bladder injury. Where are you going to have pain with a bladder injury? Well, it won’t be in the flanks, right?

It’ll be suprapubic. Patient may have an inability to void. They may have a distended abdomen. They will likely have hematuria. What about a urethral injury? What are you going to see? So this is not things to me that, this is where I say like, you don’t need to memorize this stuff.

This shouldn’t be a list you memorize. It should be, if you have renal trauma, where would the pain be? Well, it would be near the kidney. So it’d be flank pain. If you have a bladder injury, they’re going to complain of suprapubic pain. If you have a urethral injury, well, you may have an issue with like blood at the urethral meatus. You may have perineal bruising.

You may have a non-palpable prostate. All of those issues. So you want to just think it through. Something I didn’t realize could happen until I was reading through notes on this. For penile trauma that came up was a penis fracture, which is actually a rupture of the tunica albuginea, usually due to rapid swelling or deformity after sexual activity. I didn’t know that that was a thing, but that’s apparently the thing. Diagnostics.

Do you want to check for hematuria? Obviously, you might want to do a CT of the abdomen and pelvis. You can do a retrograde urethrogram, especially if you’re concerned about a urethral injury or pelvic fracture. You might do a cystoscopy or cystography. Treatment is going to be very dependent on what the issue actually is, right? So, for renal trauma, it’s usually pretty conservative, unless it’s a vascular issue. For a bladder rupture, you may be able to get away with a catheter, depending on the let the issue that’s going on, and just catheterize the patient for several days to weeks.

Or it may have to be surgically repaired. I’m not going to go into the specifics of the how and why. I don’t think that’s necessary for your PANCE. Urethral injury. So, you could do a surgical repair. If you’re going to do that, you’ll need a suprapubic catheter. That’s one thing that’s kind of interesting.

So, you they actually, you just put a catheter in suprapubically rather than through the urethra like we normally do. It’s very disturbing to see if you’ve never seen one place that way. But that’s the move because you obviously can’t leave a catheter through the urethra if you fix the urethra. And then the penile fracture, from what I understand, is a surgical repair. But again, I don’t really know too much about that. I don’t think it’s going to come up on your PANCE, so we’ll just leave it at that. Our last topic for today is vesico…

I did pretty good except for the medications today. Vesicoureteral reflux. Vesicoureteral reflux. You can mock me for not being able to pronounce it, but I’d love to hear you leave me a voicemail or a message through email with your pronunciation. Vesicoureteral reflux. This is when you get retrograde urine flow from the bladder to the ureters. And this is due to incompetent vesicoureteral junction.

So you can get a congenital short intramural ureter or familial defect or you can get a decrease, I’m sorry, increase in bladder pressure that’ll push this back up into the kidneys that direction. We want to prevent infection. We want to prevent renal scarring. That’s really the goals here. So this would be recurrent febrile UTIs, pyelonephritis in infants and young kids would be your primary, that congenital issue where the ureters aren’t functioning correctly and you’re getting backup of fluids from the bladder into the ureters rather than the other way around and up into the kidney. So this should be something that stands out to you if you see a young kid with recurrent UTIs and possibly pyelonephritis, that shouldn’t be happening.

Now, they may have flank pain. They may have hypertension. There may be some other weird signs, right? But again, most commonly in your question stems is going to be a child with multiple febrile UTIs and ultrasound showing perhaps hydronephrosis. You’re going to want to do urinalysis and culture, especially if you have a kid who’s coming in right with a febrile UTI. That’s what we’re doing. You can do a renal ultrasound looking for that hydronephrosis or scarring.

You can do a voiding cystourethrogram, which checks for that reflux. And then there are multiple grades here. So, based on reflux severity, you can get mild, moderate, or severe. For mild, you’re going to do observation, maybe prophylactic antibiotics. For a moderate grade, you’re going to want to do prophylactic antibiotics. So, something like Bactrim, cephalexin, something like that. For moderate to severe cases, you might want to do some injections and surgical ureteral reimplantation for persistent or high-grade complicated cases.

Something to consider is that about 25% of siblings have this issue as well. So it can be an issue for the entire family, I guess is the thing to notice here.

All right, so we covered a ton of ground today. Very, very excited about what we were able to do. We have a little bit further to go to get this all locked in for you. So number one, before we get into the answers for our study tips, our priming questions, I want to talk about our study tip for today. Our study tip for today is just going to include the idea of the priming questions. It’s going to include the idea of what we’re doing there. And my question for you is, now that I’ve explained it to you in the very beginning of why we do the priming questions, what they’re useful for, when they can come into play, how they can build the scaffolding for you to learn more, how can you use that in your day-to-day study?

How can you use that idea in what you’re doing normally? Can you set up a system for priming questions? Can you set up a system to go through the material a little bit before you sit through a lecture? Or if you’re going to sit down to study something, is there a way you can pull up a couple of questions? Not a lot. And that’s one of the places I find students push back on some of these ideas. Like, well, I don’t have time for that.

And I’m like, well, you might not have time for but what if you just did two or three? What if you just did one? What if you just took five minutes before you got started and ran through the headlines and made up a couple of questions, things you want to have answered? You know, this goes back to middle school English class where I learned about this, right? If you read the headlines, the headings before you start, it helps you to retain some information. So it’s an idea you can use when you’re studying. It’s an idea you can use as you’re getting ready for your PANCE.

It’s an idea you can use on your end of rotation exams. Just do a little work. It’s almost like pre-work before you get started.

All right, fantastic. Let’s finish up with our priming questions. What type of urinary incontinence causes leakage with laughing or coughing? What type of urinary incontinence causes leakage with laughing or coughing? That should be stress incontinence. What type of urinary incontinence is caused by overactive detrusor contractions and urinary urgency? What type of urinary incontinence is caused by overactive detrusor contractions and urinary urgency?

Urge incontinence. That should be pretty straightforward. An infant’s testicle remains undescended at six months of age. What’s the next step? Schedule orchiopexy. Painful, curved erections in a middle-aged man make sexual intercourse difficult. What’s the diagnosis?

Peyronie disease. A child has recurrent febrile urinary tract infections and hydronephrosis is seen on ultrasound. What condition should you suspect? You should suspect vesico-ureteral reflux. Vesico-ureteral reflux. That’s actually fun to say now that I’ve got it down. I want to run through, just before we wrap up completely for today.

Some PANCE type questions, but I’m not going to go through the full thing. I just want you to see how the stems are. Now that you have this information locked in your head, we just covered it. I want you to see how it comes. I’m not going to go through, like I said, I’m not going to go through the whole questions, but I want you to see how this comes. So for urinary incontinence, a stem might be something like this. A 54-year-old woman presents with complaints of urine leakage when she coughs, laughs, or exercises.

She denies urgency, dysuria, nocturia, or weak urinary stream. Her medical history includes two vaginal deliveries and menopause at age 50. Physical examination reveals mild pelvic laxity, but no palpable masses. Urinalysis is normal. Which of the following is the most likely diagnosis? Again, I’m not going to go through all those. I just want you to see how it’s set up and how it looks.

Let’s look at a cystocele similar. A 62-year-old woman presents with a one-year history of sensation of vaginal fullness and pressure that worsens throughout the day. She reports mild urinary frequency and occasional leakage when she coughs. The symptoms improve when she lies down. So you see the difference between the question where cystocele is the answer and the question when stress incontinence was the answer. Then it gets to be back to be kind of similar. She’s had three vaginal deliveries and entered menopause 10 years ago.

But here’s the kicker. On pelvic exam, a soft bulge is noted in the anterior vaginal wall that becomes more prominent with Valsalva.

Let’s look at genitourinary trauma. A 32-year-old man is brought to the emergency department after a motorcycle collision. He’s unable to urinate and reports lower abdominal pain. Physical exam reveals suprapubic fullness, perineal bruising, and blood at the urethral meatus. A pelvic fracture is noted on the x-ray. Which of the following is the most appropriate next step in the management? So here the answer is perform a retrograde urethrogram, because we’re not going to catheterize someone with blood at the meatus.

But I want you to see how the questions come. That’s part of the point here, and part of what we’re doing, is I want you to see how things are going to be asked, what they’re going to look like. So I don’t want to go through these and spend a ton of time on them, but I want you to be studying with that in mind. Make sense? So, with that being said, thank you for joining us today. Absolutely fun to be starting over and be heading back. It’s absolute pleasure.

Thank you for joining me. Thank you for sharing the show because that’s how I know it’s growing, and that’s how I know it is because you guys are sharing it. I don’t do much to advertise this. I don’t do anything to promote it. It’s you guys sharing with your classmates, sharing with your faculty is how more people hear about the show. So, thank you for that. Next week, we’re going to be tackling the wonderful world of infectious disease as it applies to genitourinary system.

And one thing I want to point out just before we go, don’t listen to this for entertainment. I’m not that funny. I’m not that interesting. Don’t listen to this for entertainment. There are much better ways to enjoy yourself. Listen to this to help change your behavior. Listen to this to learn something.

So what are you going to do? How will you solidify what you learned today? What steps are you going to take? This just listening was not enough? What techniques from our discussions today are you going to try? I mentioned two or three different things you can be thinking about as you approach your next set of your next study session. What are you going to do?

How are you going to change? If you’re looking to make a big change, remember for Black Friday, I’m going to be doing the PA Student Reboot Bundle, where I’m going to give you the opportunity to see and change a lot of the ways that you’re studying if you’re not getting the scores you think you deserve, if you’re working hard, not having any fun, staying up too late, not seeing any friends or family, this may be something you want to look into. Again, the details aren’t out just yet, but if you want to be one of the first to find out about it, physicianassistantexamreview.com/daily will get you into the email list, which is where you will get daily tips, tricks, techniques, philosophies, questions, and information on promotions that we’re offering. So just want to put that out to you one last time. And with that being said, I will see you next week. Take care, good luck, and start putting this stuff into practice. We’ll see you next time.