148 PANCE Question Walkthrough GU

Q1.

A 68-year-old man presents with progressive urinary hesitancy, weak stream, and nocturia over the past year. He denies dysuria, fever, or hematuria. Digital rectal examination reveals a smooth, symmetrically enlarged prostate. PSA is mildly elevated. Which of the following is the most likely diagnosis?

A. Acute prostatitis

B. Benign prostatic hyperplasia

C. Prostate cancer

D. Chronic pelvic pain syndrome

E. Bladder cancer

Correct Answer: B. Benign prostatic hyperplasia

Brian’s Notes:

This is classic BPH. Gradual obstructive urinary symptoms plus a smooth, enlarged prostate point to benign enlargement. The lack of infectious symptoms or nodularity helps rule out prostatitis or malignancy.

Explanations:

A. Acute prostatitis → would present with fever, dysuria, and a very tender prostate

B. Benign prostatic hyperplasia → correct

C. Prostate cancer → typically presents with a hard, irregular, or nodular prostate on exam

D. Chronic pelvic pain syndrome → causes pelvic discomfort without prostate enlargement

E. Bladder cancer → most often presents with painless hematuria rather than obstructive voiding symptoms and may also contain a history of smoking

Q2.

A 17-year-old sexually active boy presents to the emergency department with severe left testicular pain that began suddenly 2 hours ago while playing video games. He reports nausea but denies fever, dysuria, or urethral discharge. Physical examination shows a swollen, tender left testicle that is high riding with a horizontal lie. The cremasteric reflex is absent on the left. Urinalysis is normal. Which of the following is the most appropriate next step in management?

A. Empiric treatment with ceftriaxone and doxycycline

B. Obtain Doppler ultrasound before urology consultation

C. Attempt manual detorsion and discharge if pain resolves

D. Immediate surgical exploration

E. Administer NSAIDs and scrotal elevation

Correct Answer: D. Immediate surgical exploration

Brian’s Notes:

Sexual activity is a distractor here. Sudden onset pain, high riding testicle, and absent cremasteric reflex within 6 hours equals torsion until proven otherwise. On the PANCE, imaging never delays surgery when clinical suspicion is high.

Explanations:

A. Empiric treatment with ceftriaxone and doxycycline → This would be for epididymitis which has gradual onset and typically preserves the cremasteric reflex

B. Obtain Doppler ultrasound before urology consultation → imaging should not delay surgical management when torsion is strongly suspected

C. Attempt manual detorsion and discharge if pain resolves → manual detorsion does not replace definitive surgical fixation

D. Immediate surgical exploration → correct

E. Administer NSAIDs and scrotal elevation → appropriate for inflammatory causes, not acute ischemia

Q3.

A 42-year-old man presents to the emergency department with acute right flank pain radiating to the groin. He is nauseated but afebrile. Physical examination shows right costovertebral angle tenderness. CT scan without contrast reveals a 6 mm stone in the distal ureter. Urinalysis shows hematuria but no leukocytes or nitrites. Serum creatinine is normal, and pain improves with IV ketorolac. Which of the following is the most appropriate next step in management?

A. Immediate ureteroscopic stone removal

B. Start tamsulosin and arrange outpatient follow-up

C. Begin empiric antibiotics

D. Admit for IV fluids and pain control

E. Schedule extracorporeal shock wave lithotripsy

Correct Answer: B. Start tamsulosin and arrange outpatient follow-up

Brian’s Notes:

Tamsulosin is an alpha-1 blocker that relaxes smooth muscle in the distal ureter, increasing the likelihood of spontaneous stone passage.

Explanations:

A. Immediate ureteroscopic stone removal → reserved for obstruction with infection, renal failure, or refractory pain

B. Start tamsulosin and arrange outpatient follow-up → correct

C. Begin empiric antibiotics → no signs of infection are present

D. Admit for IV fluids and pain control → unnecessary once pain is controlled and labs are normal

E. Schedule extracorporeal shock wave lithotripsy → considered if conservative management fails or for larger stones

Q4.

A 29-year-old woman presents with 2 days of dysuria, urinary frequency, and suprapubic discomfort. She denies flank pain, fever, chills, nausea, or vaginal discharge. Physical examination shows mild suprapubic tenderness without costovertebral angle tenderness. Urinalysis reveals positive leukocyte esterase, positive nitrites, and more than 50 white blood cells per high-power field. Which of the following is the most appropriate diagnosis?

A. Acute pyelonephritis

B. Acute uncomplicated cystitis

C. Interstitial cystitis

D. Urethritis

E. Vaginitis

Correct Answer: B. Acute uncomplicated cystitis

Brian’s Notes:

This presentation localizes to the bladder. Dysuria, frequency, suprapubic pain, and a clearly positive urinalysis without systemic symptoms are classic for uncomplicated cystitis.

Explanation:

A. Acute pyelonephritis → would expect fever, flank pain, nausea, or costovertebral angle tenderness

B. Acute uncomplicated cystitis → correct

C. Interstitial cystitis → chronic pelvic pain with negative urinalysis and no infection

D. Urethritis → typically associated with sexually transmitted infections and urethral discharge

E. Vaginitis → causes vaginal symptoms such as discharge, odor, or pruritus rather than urinary findings

Q5. Genitourinary System

Length: Medium | Bloom’s: 3 | Difficulty: Medium

Subtopic: Epididymitis | Task Area: Managing Patients, Pharmaceutical Therapeutics | Population: Adult | Surgical Topic: No

A 26-year-old man presents to the emergency department with 2 days of gradually worsening right scrotal pain and swelling. He reports dysuria and urethral discharge. On further questioning, he states that he is sexually active with more than one partner and does not consistently use condoms. Temperature is 36.9°C (98.4°F), heart rate 82 beats per minute, blood pressure 124/76 mmHg, and respiratory rate 14 breaths per minute. Physical examination shows an enlarged, tender right hemiscrotum with erythema. Elevation of the scrotum partially relieves his pain. The cremasteric reflex is intact bilaterally. Urinalysis shows leukocytes. Which of the following is the most appropriate treatment?

A. Immediate surgical exploration

B. Ceftriaxone and doxycycline

C. Oral ciprofloxacin

D. NSAIDs and scrotal support only

E. High-dose trimethoprim-sulfamethoxazole

Correct Answer: B. Ceftriaxone and doxycycline

Brian’s Notes:

This presentation is most consistent with epididymitis due to a sexually transmitted infection. Gradual onset pain, urethral discharge, preserved cremasteric reflex, and relief with scrotal elevation point away from torsion. In sexually active men under 35, empiric treatment targets gonorrhea and chlamydia.

Explanation:

A. Immediate surgical exploration → indicated for suspected testicular torsion

B. Ceftriaxone and doxycycline → correct; covers Neisseria gonorrhoeae and Chlamydia trachomatis

C. Oral ciprofloxacin → used for enteric organisms in older men or those with urinary instrumentation

D. NSAIDs and scrotal support only → adjunctive therapy, not definitive treatment

E. High-dose trimethoprim-sulfamethoxazole → not first-line therapy for sexually transmitted epididymitis

Q6. A 74-year-old man is brought to the emergency department by his daughter because he has been increasingly confused over the past 2 days. She reports that for several months he has been taking a very long time to urinate, going back and forth to the bathroom at night, and often saying that he still feels the urge to urinate even after he finishes. She also notes that his lower abdomen has looked more distended recently and that his pants have become tighter around the waist. His medical history includes hypertension and osteoarthritis. Medications include lisinopril and daily ibuprofen.

He is afebrile with blood pressure 158/92 mmHg and heart rate 88 beats per minute. Physical examination reveals a distended, mildly tender suprapubic region. Digital rectal examination shows a markedly enlarged, smooth prostate. A bedside bladder scan demonstrates 900 mL of retained urine. Laboratory studies show BUN 58 mg/dL and creatinine 3.1 mg/dL, increased from a baseline of 1.0 mg/dL three months earlier. Urinalysis shows no protein and no casts. Which of the following best categorizes the cause of this patient’s acute kidney injury?

A. Prerenal azotemia

B. Acute tubular necrosis

C. Postrenal obstruction

D. Acute interstitial nephritis

E. Glomerulonephritis

Correct Answer: C. Postrenal obstruction

Brian’s Notes:

This is a classic postrenal acute kidney injury. Family-observed voiding difficulty, suprapubic distention, a very large post-void residual, and a bland urinalysis point to urinary outflow obstruction rather than intrinsic renal disease.

Explanation:

A. Prerenal azotemia → would be associated with volume depletion or hypotension and does not explain severe urinary retention

B. Acute tubular necrosis → typically produces muddy brown casts and is not associated with bladder distention

C. Postrenal obstruction → correct

D. Acute interstitial nephritis → usually presents with pyuria, eosinophils, rash, or fever

E. Glomerulonephritis → would cause hematuria, proteinuria, and often red blood cell casts

Q7. A 38-year-old woman presents to clinic after noticing blood in her urine on two occasions over the past week. She has no pain with urination, no flank pain, and no fever. She has no history of kidney stones. She does not smoke. Physical examination is normal. Urinalysis in clinic shows more than 25 red blood cells per high-power field with no protein, leukocytes, or nitrites. Urine pregnancy test is negative. Which of the following is the most appropriate next step in evaluation?

A. Reassurance and repeat urinalysis in 6 months

B. Empiric antibiotics for urinary tract infection

C. CT scan of the abdomen and pelvis with contrast

D. Cystoscopy

E. Renal ultrasound

Correct Answer: E. Renal ultrasound

Brian’s Notes:

This patient has painless hematuria without signs of infection, stones, or glomerular disease. In a young, low-risk patient, the next step is to evaluate the upper urinary tract with noninvasive imaging. Renal ultrasound helps assess for structural causes while avoiding unnecessary radiation.

Explanation:

A. Reassurance and repeat urinalysis in 6 months → hematuria confirmed on urinalysis should be evaluated, not ignored

B. Empiric antibiotics for urinary tract infection → no dysuria, leukocytes, or nitrites to suggest infection

C. CT scan of the abdomen and pelvis with contrast → reserved for higher-risk patients or concerning findings

D. Cystoscopy → more appropriate in older patients, smokers, or if initial imaging is abnormal

E. Renal ultrasound → correct; appropriate initial imaging to evaluate kidneys and collecting system

Q8. A 24-year-old woman at 14 weeks’ gestation presents for a routine prenatal visit. She feels well and denies dysuria, urinary frequency, flank pain, fever, or vaginal symptoms. Vital signs are normal. As part of routine screening, a urine culture is obtained and grows more than 100,000 CFU/mL of Escherichia coli. Urinalysis shows leukocytes but no nitrites. Which of the following is the most appropriate management?

A. No treatment is needed because she is asymptomatic

B. Nitrofurantoin therapy

C. Trimethoprim-sulfamethoxazole therapy

D. Ciprofloxacin therapy

E. Repeat urine culture in the third trimester

Correct Answer: B. Nitrofurantoin therapy

Brian’s Notes:

Asymptomatic bacteriuria must be treated in pregnancy due to the risk of pyelonephritis and preterm labor. Nitrofurantoin is an appropriate first-line option in the second trimester.

Explanation:

A. No treatment is needed because she is asymptomatic → asymptomatic bacteriuria requires treatment in pregnancy

B. Nitrofurantoin therapy → correct; safe and effective in the second trimester

C. Trimethoprim-sulfamethoxazole therapy → avoided in the first trimester and near term due to fetal risks

D. Ciprofloxacin therapy → fluoroquinolones are contraindicated in pregnancy

E. Repeat urine culture in the third trimester → treatment should not be delayed

Q9. A 3-year-old girl is brought to clinic for follow-up after her second febrile urinary tract infection in the past year. Her mother reports that during infections she has high fevers and vomiting but no respiratory symptoms. Physical examination today is normal. Renal ultrasound performed after the most recent infection shows mild bilateral hydronephrosis. Which of the following is the most likely underlying diagnosis?

A. Posterior urethral valves

B. Neurogenic bladder

C. Vesicoureteral reflux

D. Ureteropelvic junction obstruction

E. Wilms tumor

Correct Answer: C. Vesicoureteral reflux

Brian’s Notes:

Recurrent febrile UTIs in a young child raise concern for vesicoureteral reflux. Hydronephrosis without a focal mass or obstruction supports urine flowing backward rather than a fixed anatomic blockage.

Explanation:

A. Posterior urethral valves → occur only in males and typically present in infancy with bladder outlet obstruction

B. Neurogenic bladder → associated with neurologic disease or spinal abnormalities

C. Vesicoureteral reflux → correct

D. Ureteropelvic junction obstruction → usually causes unilateral hydronephrosis without recurrent infections

E. Wilms tumor → presents as a palpable abdominal mass, not recurrent infections

Q10. A 55-year-old man presents for an annual health maintenance visit. He has no urinary complaints. His medical history is unremarkable. His father was diagnosed with prostate cancer at age 62. He asks whether he should be screened for prostate cancer. Physical examination is normal. Which of the following is the most appropriate recommendation?

A. No screening is recommended for prostate cancer

B. Begin prostate-specific antigen testing now

C. Begin prostate-specific antigen testing at age 65

D. Obtain prostate MRI as an initial screening test

E. Perform digital rectal examination only

Correct Answer: B. Begin prostate-specific antigen testing now

Brian’s Notes:

Men with a first-degree relative with prostate cancer are considered higher risk. Screening discussions begin earlier in these patients, typically around age 45–55. PSA testing is the initial screening modality.

Explanation:

A. No screening is recommended for prostate cancer → screening is recommended in higher-risk patients after shared decision-making

B. Begin prostate-specific antigen testing now → correct

C. Begin prostate-specific antigen testing at age 65 → too late for a patient with increased risk

D. Obtain prostate MRI as an initial screening test → MRI is not used for initial screening

E. Perform digital rectal examination only → DRE alone is insufficient as a screening strategy