S2 E095 Urology Problems & how to beat the PANCE

Hello and welcome to the Physician Assistant Exam Review Podcast. This week we’re going to be talking about congenital and acquired issues of the genitourinary system. I’m Brian Wallace, founder and creator here at Physician Assistant Exam Review, where we teach core medical content and how to dominate school and ultimately pass the PANCE. That’s our goal, right, is to get you through school, pass the PANCE, and we do that by teaching you medical content, but that’s not all we teach. Those are not the same thing. They are not equivalents, and we’ll talk about that in the study tip section of our show today, how those things are related, but certainly not the same. First, though, if you find today’s show helpful, if you like the way I teach, if you find it inspirational, please share it with a friend, a classmate, or your entire class.

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All right. So we have a very short show for you today, short topic-wise. I’m just going to run through congenital and acquired issues here on the blueprint. We will pick up in the next episode of Physician Assistant Exam Review with infectious issues of the genitourinary tract. And I wanted to separate that section out on its own just so you can isolate it in your brain and we’re not covering multiple topics that you have trouble holding on to. So this section is going to be short in favor of isolating infectious issues.

So let’s jump into our priming questions for today. These are designed to get your brain working and moving. I’m going to explain to you as we go through them. I don’t expect you to know the answers to these off the top of your head. It depends a little bit on where you are in school, where you are getting ready. But the reality is you’re not going to know the answer to all of these. I would be very impressed if you did.

But the key is, I want you thinking. I don’t want you just skipping over them. These are to get your brain ready, to get your brain warmed up, to get you engaged in the show. So it’s not just me talking, it’s you working. By what age should you refer a patient with cryptorchidism to urology? By what age should you refer a patient with cryptorchidism to urology? How will a patient with vesicoureteral reflux present?

How will a patient with vesicoureteral reflux present? Think about it for a second. Even if you don’t know what that means, what might it mean, considering we’re covering genitourinary, and how do you think they would present? Even if you’re wrong, think it through. Describe what a voiding cystourethrography is. Well, I’m struggling I’m going to struggle with some words today. A voiding cystourethrography.

Again, think it through. Don’t just skip and expect me to give you the answers. I want you thinking and concentrating. That’s how the stuff sticks. Letting it wash over you, not the same.

All right. So, what’s cryptorchidism? At this point, I think most people are familiar with this term. This is where one or both of the testes are absent from the scrotum. Generally, this is picked up on a pediatric physical exam. Risk factors include things like premature birth and low birth weight. I was reading, as I was going through this, that somewhere around 30% of boys with a premature birth will have cryptorchidism.

But the true incidence is, overall, is more like one percent, because by the time you get to a year, usually the testes will have descended. Not always. So that’s where your 1% comes in. So cryptorchidism is that the testes is not in the scrotum, but that doesn’t mean you have a problem yet. It’s not a reason for panic. It’s a reason to pay attention. So again, this is usually picked up on a routine physical exam.

You can do an ultrasound or an MRI to look for that testis and make sure it’s present and it’s on its way. But initially, you’re going to do watchful waiting. There’s no reason to rush to treat this patient, to rush this patient off to surgery if you have a six-month-old with one undescended testis. Like I said, the majority will continue to descend and be descended by 12 months. But this should be addressed between 12 months and 24 months because there’s concern about infertility down the road. You’re going to want to refer these patients, from what I understood, about at about six months, you’re going to want to start talking about with a urologist about these patients. It doesn’t mean that there’s going to be any treatment necessary.

It doesn’t mean that there’s going to be surgery necessary. It just means you want to get that conversation started. All of these kinds of questions, you’re going to find different answers to, right? Because there’s no hard, cold fact on when this should be taken care of. It’s not that straightforward. It’s a little gray, right? There’s risks to treatments.

There’s risks to surgeries. Everything’s getting better, but there’s still risks involved. So you’re gauging your risk-reward profiles in all of these things. But beginning the conversation at about six months, it seems to be what I found throughout the literature. And the surgery in this case would be an orchiopexy. You can also use HCG injections, which can raise the testosterone levels, and that’s often an effective treatment before you get to surgery. But again, that’s treatments that’s most likely going to be discussed with the urologist.

Next, we have Peyronie’s disease, which is this is a scar tissue built up within the penis, creating a deformity in the shape of the erect penis. So you get what we normally think of as a curvature in the penis, but it can just be denting or firm, hard, fibrous tissue within the penis.

Now, you this can cause this causes some obvious problems, right? It causes an issue where sexual intercourse is painful, difficult, or impossible. It can lead to erectile dysfunction.

Now, I didn’t come across this specifically in the literature, but I’m sure that also has to do with the fact that the person with Peyronie’s disease, if they’re struggling or having or sex is painful, then they’re going to withdraw from their partner. Then they’re going to get depressed, and they’re going to have other issues, and the erectile dysfunction maybe just be part of that. So, again, we’re treating patients, not necessarily specifically diseases. Here on our test, we’re still we’re sticking to diseases, but in your clinical practice, consider the patient, right? The overall effect this is having on them, their relationships, the life that they’re living. Labs and studies. Ultrasound can be used to confirm the diagnosis.

You can find that scar tissue within the penis using ultrasound. Not 100% necessary. This can be a clinical diagnosis, but that’s available to you. Treatments. Mild conditions may not be a problem at all. You can get some scar buildup in the shaft of the penis, and it may not cause that same curvature. It may not be that distinct.

It may not be that 30-degree angle that they talk about. And it also may resolve on its own. You can do a steroid injection to break up the scar tissue. But this may or may not be helpful. And you can surgically remove scar tissue. The problem is when you surgically remove scar tissue or you do something like a steroid injection to break it up, there are varying degrees of success here. So doing surgery to go after scar tissue can create more scar tissue, right?

So I just want you to understand that going in, that that’s a possibility. It’s an option, but it doesn’t mean it’s 100% curative. And that’ll solve all the problems. But it’s on the table. It’s an option, depending on the degree of severity and the problems the individual is having.

Next, we go to the one that’s going to make you guys laugh at the way that I pronounce things, the vesicoureteral reflux. Oh, I nailed it. Vesicoureteral reflux. This is when urine moves backwards through the renal system. So you’re familiar. Normally, urine is made in the kidney. It travels from the kidney down the ureter.

Into the bladder. And then it’s excreted from the bladder through the urethra. Right? That all makes sense. We got that. When we get reflux, reflux just means moving backwards, right? So it’s like esophageal reflux.

We get acid from the stomach coming back up into the esophagus. Here we get vesicoureteral reflux. Vesico means bladder and then into the ureter. So from the bladder into the ureters. So what normally happens is there’s a valve, basically the ends of the ureters kink off and then open to allow urine to flow from the ureter into the bladder. And then they kink off to keep the bladder from pushing urine back into the ureters and back into the kidneys. Well, if that valve, if that kinking off at the end of those isn’t functional for one reason or another, usually it’s a congenital issue.

But if that system isn’t working, as the bladder squeezes, it’s creating pressure, and it would just as soon push back up the ureter as it would out through the urethra, right? It’s not deciding which way to go. It’s just a high-pressure to low-pressure system. So if that valve isn’t working, some of the urine gets pushed back up the ureters and into the kidneys. Make sense? So it’s a pretty straightforward problem that you can picture in your mind. And to me, that’s a big part of remembering this stuff is being able to create that picture in your mind.

And so we actually do a lot of cystoscopy where I work because we’re working, I do a lot of urogynecology and GYN surgery. So if we do a, if we put in a sling for incontinence like we talked about previously, you want to put a scope into the bladder and look around and make sure you didn’t cause any damage that you didn’t accidentally put a stitch into the bladder. You want to look and make sure everything’s fine. Same thing for if we do a hysterectomy, especially a total hyst, where you’re taking up the cervix, you’re very close to the ureters, and you want to make sure that those ureters are still functioning. So, one way to do that is you do a cystoscopy. You take a scope, and you put it up through the urethra, and you look inside the bladder, and then you can actually watch efflux from each ureter, bilaterally, to make sure that those ureters are still functioning properly. That’s one way to to be a little more confident.

You haven’t damaged any of the systems while you’re in there, because it’s hard to see the ureters. Most of the time, the one on the right, you can see a good amount. The one on the left a little tougher. So it’s hard to make sure that you’re in the right places.

Now, you know that you are and you feel very comfortable in most cases, but you double check it by taking a scope and looking into the bladder and watching the efflux from the ureters. So my point being, I can picture in my head the way the ureters work when urine comes out of them and how they close back down when the urine stops. And I can picture in my head if that’s just now an open tube instead of a valve how when the bladder contracts it pushes the urine back up into the bladder. So that should make sense. Now what are the problems that come from this? Why is it an issue that has to be solved? So think it through for a minute.

How are these patients going to present? Are they going to present with abdominal pain? Well, maybe. Are you going to be able to see that urine’s traveling back up the ureters? No, that’s not how this is going to work. But what you’re probably going to get is a urinary tract infection, especially in a kid. Urinary tract infections in very young children are a cause to look into what might be going on here, what’s actually causing the problem.

Dilation of the kidneys. Urinary tract infections will present with a lot of different symptoms. So, I jokingly said about abdominal pain, but they can get abdominal pain. They can get nausea, they can get fevers, they can get a lot of different things, especially in kids. That can be a weird presenting signs. But if you see a urinary tract infection in a kid, you should be considering vesicoureteral reflux. Not that it’s a major common issue, but it should be on your list someplace.

Labs and studies and ultrasound is going to be a good way to take a look at this. You’re going to look at the kidneys and the ureters and see if they’re dilated. If they’re bigger than they should be, if the ureters are holding more urine in them than they should be. A urinalysis with cultures to tell if you have an infection and see what’s going on. And then a voiding cystourethrography. Our question from the beginning, a voiding cystourethrography.

Now, I didn’t know what that was, so I had to look it up. And what it turns out to be is that the bladder is filled with contrast dye, and then the patient voids while being observed with fluoroscopy, which totally makes sense, right? And I equate that to a barium swallow for the urinary tract. We have you swallow a radio opaque dye and then use fluoroscopy to watch that dye move through the system so we can see how it moves through the system. Well, the same thing is how this works. You inject a radio opaque dye into the bladder, and then you use fluoroscopy to watch how that fluid moves as the patient voids. If you watch it move back up the ureters, you know you have a problem.

Now, I am wondering to myself how you do this with a small child and get them to void while holding still so you can watch under fluoroscopy. I’ve never participated in one of these or seen how it’s done, but that seems like an interesting, difficult thing to try to pull off and get good images. But, you know, I guess that’s what they do. So, anyway, voiding cystourethrography, think of it like a barium swallow for the urinary tract. You’re going to watch how the fluids move within that tract, and that’s going to be really, really good for diagnosing vesicoureteral reflux. And that’s the last time I’m going to say those two words, I think. Treatments.

Mild disease may resolve with time, and as the child grows, the ureters may find their ways, and those valves may increase within their strength, and it may resolve on its own. One major concern with these patients is infections. So you want to avoid bladder infections. You want to avoid urinary tract infections. You want to avoid pyelonephritis, obviously. So prophylactic antibiotics are given in an effort to prevent infections in these patients.

Now, if the disease is very bad, and they’re having lots of problems, and they’re having lots of infections, then you’re going to need surgical correction. We’re not going to go into exactly what that means here. But that’s going to be the next step. And that’s the next progression in a lot of these things, right? For your PANCE, it doesn’t go into what the specific surgeries are, how they work. What you need to know is that surgery is an option.

All right, let’s talk about our study tip for today. That’s going to wrap up this section. Like I said, it’s going to be pretty short. Our study tip for today. One of the things I’ve been, so starting April 1st, I’m launching a 33 Days to Pass the PANCE class course. I’m not sure the best way to call it. It’s almost like a boot camp.

And what I’m going to do, what I’m doing with the people who have joined is we’re going to go through medical content. We’re going to do it as a group to get as much working together as we can so that people can feel as though they’re part of a group, that they’re going to have a place that’s safe, that they can express their concerns, get answers to questions, put up ideas for how to study better, all things like that, so that we can do it together. The other thing that I’m going to provide is information on how to play the game, how to study and pass an exam of this magnitude. And I think that’s something that’s sorely missing. I think we focus a lot on medical content, and we should. But medical content isn’t necessarily the answer. I’ve been hearing from a lot of people recently who have failed the PANCE, who have failed the PANCE with very low scores.

And when I pushed around about this, I found that the overall rate is down, passing rate. And one of the ways, and what I found is when I talk to or I’ve worked with people who have failed the PANCE, I almost never have thought, wow, this person doesn’t know what they’re talking about. This person doesn’t have a clue. If you’ve gotten this far, you have spent months or years preparing for this test learning medical content. You’ve been working very hard to get as much medical content into your brain as you possibly can. And rarely is the problem not having enough medical content in your brain. From where I sit, the problem is not being able to get that content out of the brain.

Not understanding how to take tests, how to study for tests. Not understanding that it’s a game. Most people at this level did very well in undergrad. They were able to use pure brain power and hard work to do well in undergrad. Then they showed up to PA school. And again, they’re smart enough, but they’re struggling and we’re having to work a lot harder and a lot longer, but are able to pull it off. But then as the PANCE approaches, it’s a different animal.

It is a tremendous amount of knowledge. And then the day itself is like running a marathon. It is a huge undertaking to sit in that chair for hour after hour answering test questions. And then I actually think it’s funny when people email me and they say, Brian, I can’t believe I failed. I’m such a good student. I’ve been such a great student. My patients love me.

I have a job lined up. Everything looks fabulous. I can’t believe I failed. And then they start to think that they’re not going to be a good practitioner because they failed this test. Then they start to wonder why, if their patients love them and their preceptors love them, they could possibly have failed. And I want to explain to you in today’s study tip that this thing is not about you being a good practitioner. This thing is not about your empathy, your ability to connect with your patients and your preceptors.

It is not about you being able to treat your patients. It’s about this test, and only about this test. And just like I’m watching my kids soccer tournament this weekend, thinking and thinking about this, if all we ever if all I ever taught him was foot skills, and all we ever worked on was dribbling in and out of cones and moves, he would have that down really well. But would that be enough to make him a good player? Would that be enough if all we ever did was work on his footwork? No, there’s so many more aspects to the game. There’s seeing the field, there’s passing, there’s working with your teammates.

Well I find the same thing with medical content as you approach the PANCE, and even as you move through PA school. There’s so much focus on medical content. And again, there should, just like footwork and soccer, there should be a ton of focus on it, but not at the exclusion of everything else. And one way I think that students can pick up a lot of points, do a lot better, get a lot more sleep at night, build a lot more confidence, is through increasing their skills outside of medical content. By getting better at test taking, by getting better at test taking, by getting better at studying. There are different methods, different ways, different things you can do to improve all of those areas. Those are all skills you can get better at.

And I feel like that’s where we’re dropping the ball a lot. We’re piling up the medical content. We’ve got books stacked to the ceiling. We’ve got PDFs filling our computers on medical content. But we don’t take any time to work on test-taking skills, study skills, anxiety management, discipline. Those are the things you need to develop in order to get through PA school and get through the PANCE. And if you use brute force to get through school, the PANCE is hard to use brute force to get through.

It really is. It’s just so much. And I think you can do better. I think you can easily do better. And that’s what I wanted to share with you today. Take a little time to work on your test taking. Take a little time to work on how you study.

Think about how you study. Think about your approach to test taking. Think about this whole thing as a game. That’s how I approach my tests. That’s how I approach my PANCE and my PANRE. As if it were a playoff game. And I was nervous, but I wanted to show what I could do.

And I understood the rules, and I had a strategy and an approach and a way to handle it, I might not pass. I might lose that game. But I understand what’s at stake, and I understand why it’s played, and I understand how to play it. And I don’t attach my whole identity to the outcome of this one particular game, this one particular test. If things don’t go well, I come back tomorrow. You can’t beat me because I’m coming back tomorrow. Don’t have to worry about it if I fail.

If I fail, I know what’s going to happen. I’m coming back tomorrow. I’m not worried about it. I’m not concerned. I don’t spend any time thinking about it because I know what’s going to happen. I’m going to do my best. And if that’s not enough, I’m going to come back tomorrow and try again.

But please understand that it’s a game. It’s not a reflection on the type of person you are or the type of practitioner you will be.

All right. Let’s move on to answering our study topic, our study questions for today. Priming questions. I knew I’d get it eventually. By what age should you refer a patient with a cryptorchidism to urology? By what age should you refer a patient with cryptorchidism to urology? Now this is going to be a varying answer, right?

There’s no hard, fast solution to this, but I would say six months is probably the number I came across the most. Again, we’re not going to necessarily do anything at six months, but that’s about when we should probably start talking with somebody. How will a patient with vesicoureteral reflux present? You can picture this by now. If I were asked this question, I would choose a UTI in a kid. Describe voiding cystourethrography. And this is where we put radiopaque dye into the bladder and then watch the patient void using fluoroscopy.

So, consider what a barium swallow would look like. The same idea for the urinary tract.

All right, great. That’ll take us out for today. We have a couple more in urology before we move on down the road. The two things I want you to take away from today are two things I’m going to ask of you. One is please share the show. If you liked what you got out of today’s show, please share it with someone who would also benefit from the material. And number two is to, if you want more of these episodes, go to physicianassistantexamreview.com/podcast to get each and every show.

All right, great, I’m so thankful you’re here today. Take care, good luck on your exams.