Systems Pathology II - Exam 3 Cases

Jalen reports with a complaint of severe, sharp pain in his right scrotum; the pain began suddenly about 3 hours ago while playing basketball. Pain has been intensifying and persistent, denied any trauma or recent strenuous physical activity. He is unable to find a position of comfort, unable to urinate since pain began; no changes in habits and denies any pervious experience of this; no family history. Genitourinary (right scrotum significantly swollen, firm and tender testicle; left is positioned higher than the left with a horizontal orientation, cremasteric reflex absent on right; left testicle appears normal in size, shape, position).

What are 3 possible differential diagnoses?

Testicular Torsion (most likely), Epididymitis, Orchitis, Incarrcerated Inguinal Hernia, Torsion of Appendix Testis

Jalen reports with a complaint of severe, sharp pain in his right scrotum; the pain began suddenly about 3 hours ago while playing basketball. Pain has been intensifying and persistent, denied any trauma or recent strenuous physical activity. He is unable to find a position of comfort, unable to urinate since pain began; no changes in habits and denies any pervious experience of this; no family history. Genitourinary (right scrotum significantly swollen, firm and tender testicle; left is positioned higher than the left with a horizontal orientation, cremasteric reflex absent on right; left testicle appears normal in size, shape, position).

What diagnostic tools would be used to confirm diagnosis?

Scrotal Ultrasound (absent of blood), Urinalysis (normal, no evidence of infection or hematuria), Pelvic Ultrasound (rule out abdominalities)

Jalen reports with a complaint of severe, sharp pain in his right scrotum; the pain began suddenly about 3 hours ago while playing basketball. Pain has been intensifying and persistent, denied any trauma or recent strenuous physical activity. He is unable to find a position of comfort, unable to urinate since pain began; no changes in habits and denies any pervious experience of this; no family history. Genitourinary (right scrotum significantly swollen, firm and tender testicle; left is positioned higher than the left with a horizontal orientation, cremasteric reflex absent on right; left testicle appears normal in size, shape, position).

What does management for this condition look like?

Immediate - surgical emergency

Post-Op - orchidopexy, analgesics and antiemetics meds (for pain and nausea), follow up in 1-2 weeks

Rex presents with a 6-month history of progressively worsening urinary symptoms. increased frequency (especially at night - nocturia), incomplete urination sensations, weak and inconstant stream, mild dribbling at end of urination. DRE showed prostate enlarged but non-tender, with smooth and firm consistency. PSA elevated for his age (5.2 instead of <4), TRUS prostate volume 55mL (typically <30mL), no signs of malignancy, Uroflowmetry had a reduced flow rate. Consistent with bladder outlet obstruction (Benign Prostatic Hyperplasia)

What does conservative management measures look like?

Lifestyle modifications (reduce liquid intake before bed; avoid caffeine, alcohol, and artificial sweeteners), Bladder training (timed voiding - scheduled bathroom visits; urge suppression - suppress urge to follow schedule; Kegel Exercise (strengthen pelvic floor); Double Voiding - after urinating, stay and wait a few before urinating again to fully empty bladder)

Rex presents with a 6-month history of progressively worsening urinary symptoms. increased frequency (especially at night - nocturia), incomplete urination sensations, weak and inconstant stream, mild dribbling at end of urination. DRE showed prostate enlarged but non-tender, with smooth and firm consistency. PSA elevated for his age (5.2 instead of <4), TRUS prostate volume 55mL (typically <30mL), no signs of malignancy, Uroflowmetry had a reduced flow rate. Consistent with bladder outlet obstruction (Benign Prostatic Hyperplasia)

What are pharmacological options?

Alpha-blockers (relax smooth muscles) and 5-alpha reductase inhibitors (reduce prostate size, inhibits conversion of testosterone to DHT)

Rex presents with a 6-month history of progressively worsening urinary symptoms. increased frequency (especially at night - nocturia), incomplete urination sensations, weak and inconstant stream, mild dribbling at end of urination. DRE showed prostate enlarged but non-tender, with smooth and firm consistency. PSA elevated for his age (5.2 instead of <4), TRUS prostate volume 55mL (typically <30mL), no signs of malignancy, Uroflowmetry had a reduced flow rate. Consistent with bladder outlet obstruction (Benign Prostatic Hyperplasia)

What does follow up, patient education, and prognosis look like?

Follow Up (regular 6 months, monitor symptoms and medications, consideration for surgery), Patient Education (informing that it's noncancerous and treatable but can worsen, cover potential side effects of medication), Prognosis (can lead to more severe complications, with appropriate management patient can expect improved symptoms and quality of life with the possibility of not needing surgery)

Dalton presents with sudden onset of server lower back pain that is radiating to the groin on the right side. Pain started 6 hours ago, was sharp and intermittent at first, intensity has progressively worsened, rated a 9/10 on the pain scale. Also reports nausea and vomiting due to pain, no fever or dysuria. No visible blood, recent changes, traumas, etc. abdominal exam showed no abnormal results, renal exam noted tenderness over right flank (positive costovertebral angle tenderness). Urinalysis showed slightly turbid urine, no blood pyuria or bacteria present. Non-contrast CT of abdomen and pelvis showed 5mm stone in the right renal pelvis; no signs of hydronephrosis seen. Blood test showed normal kidney function.

What are the possible differential diagnoses?

Kidney Stone/Nephrolithiasis (most likely), Appendicitis, Pyelonephritis, MSK pain

Dalton presents with sudden onset of server lower back pain that is radiating to the groin on the right side. Pain started 6 hours ago, was sharp and intermittent at first, intensity has progressively worsened, rated a 9/10 on the pain scale. Also reports nausea and vomiting due to pain, no fever or dysuria. No visible blood, recent changes, traumas, etc. abdominal exam showed no abnormal results, renal exam noted tenderness over right flank (positive costovertebral angle tenderness). Urinalysis showed slightly turbid urine, no blood pyuria or bacteria present. Non-contrast CT of abdomen and pelvis showed 5mm stone in the right renal pelvis; no signs of hydronephrosis seen. Blood test showed normal kidney function.

What does management for this condition look like?

Acute pain relief by medications, hydration, tamsulosin (alpha blocker), observe (since less than 6mm stone, likely for spontaneous passage/passing of stone)

Dalton presents with sudden onset of server lower back pain that is radiating to the groin on the right side. Pain started 6 hours ago, was sharp and intermittent at first, intensity has progressively worsened, rated a 9/10 on the pain scale. Also reports nausea and vomiting due to pain, no fever or dysuria. No visible blood, recent changes, traumas, etc. abdominal exam showed no abnormal results, renal exam noted tenderness over right flank (positive costovertebral angle tenderness). Urinalysis showed slightly turbid urine, no blood pyuria or bacteria present. Non-contrast CT of abdomen and pelvis showed 5mm stone in the right renal pelvis; no signs of hydronephrosis seen. Blood test showed normal kidney function.

What does follow up and patient education look like?

Follow Up (after 48 hours, patient report less pain, passes the stone during urination; advised to follow-up in 1-2 weeks for repeat imaging to ensure complete passing) and Patient Education (stone prevention - increase fluid intake, modify diet (avoid excessive oxalate-rich foods, reduce salt, increase intake of fruits and veggies), follow up consultation with urologist for long-term management and eval for possible underlying conditions

Lyle presents with complaints of hematuria (bloody urine) for the last 2 weeks, mention increased frequency of urination (especially at night) and incomplete emptying sensation. He mentioned he is a smoker of 50 years (about 1 pack/day). Abdomen and Pelvic exams found typically/normal findings.

What are the differential diagnoses?

Bladder Cancer (most likely), UTI, Bladder Stones, Benign Prostatic Hyperplasia, Renal Cell Carcinoma

Lyle presents with complaints of hematuria (bloody urine) for the last 2 weeks, mention increased frequency of urination (especially at night) and incomplete emptying sensation. He mentioned he is a smoker of 50 years (about 1 pack/day). Abdomen and Pelvic exams found typically/normal findings. Additional workup findings: urinalysis (hematuria, no signs of infection), Urine cytology (suspicious of malignant cells), CT Urogram (evaluate for mass/obstruction of kidneys, ureters, and bladder), Cystoscopy (bladder lined with tumor/lesion; biopsy done to confirm malignancy) - revealed a 3 cm mass on posterior wall of bladder, biopsy confirmed high-grade urothelial carcinoma (bladder cancer).

What does the treatment plan and follow up look like?

Surgery (TURBT - remove visible tumor and assess depth of invasion; radical cystectomy if needed), Chemotherapy (intravesical chemo go directly into bladder via catheter), Follow up (regular cystoscopy and urine cytology every 3-6 months for 2 years then annually)