A 56-year-old man is brought to the emergency department 25 minutes after he was involved in a high-speed motor vehicle collision where he was the unrestrained passenger. He has severe lower abdominal and pelvic pain. On arrival, he is alert and oriented. His pulse is 95/min, respirations are 22/min, and blood pressure is 106/62 mm Hg. Examination shows severe tenderness to palpation over the lower abdomen and over the left anterior superior iliac spine. There is no limb length discrepancy. Application of downward pressure over the pelvis shows no springy resistance or instability. Rectal examination is unremarkable. A focused assessment with sonography shows no free fluid in the abdomen. There is no blood at the urethral meatus. Placement of a Foley catheter shows gross hematuria. An x-ray of the pelvis shows a fracture of the left pelvic edge. Which of the following is the most appropriate next step in management?

External fixation of the pelvis

A 31-year-old obese Caucasian female presents to the Emergency Department late in the evening for left lower quadrant pain that has progressively worsened over the last several hours. She describes the pain as sharp and shooting, coming and going. Her last bowel movement was this morning. She has also had dysuria and urgency. Her surgical history is notable for gastric bypass surgery 2 years prior and an appendectomy at age 9. She is sexually active with her boyfriend and uses condoms. Her temperature is 99.5 deg F (37.5 deg C), blood pressure is 151/83 mmHg, pulse is 86/min, respirations are 14/minute, BMI 32. On physical exam, she has left lower quadrant tenderness to palpation with pain radiating to the left groin and left flank tenderness on palpation. Her urinalysis shows 324 red blood cells/high power field. Her pregnancy test is negative. What is the next best step in management?

A KUB (kidneys, ureters and bladder) plain film

A 61-year-old G4P3 presents with a 5-year history of involuntary urine loss on coughing, sneezing, and physical exertion. She denies urine leakage at night. She has been menopausal since 51 years of age. She is otherwise healthy and is not on any medications, including hormone replacement therapy. The weight is 78 kg (172 lb) and the height is 156 cm (5.1 ft). The vital signs are within normal limits. The physical examination shows no costovertebral angle tenderness. The neurologic examination is unremarkable. The gynecologic examination revealed pale and thin vulvar and vaginal mucosa. The external urethral opening appears normal; there is urine leakage when the patient is asked to cough. The Q-tip test is positive. The bimanual exam reveals painless bulging of the anterior vaginal wall. Which of the following findings are most likely to be revealed by cystometry?

Normal residual volume, no involuntary detrusor contractions

Increased residual volume, involuntary detrusor contractions on maximal bladder filling

Normal residual volume, involuntary detrusor contractions on minimal bladder filling

Normal residual volume, involuntary detrusor contractions on maximal bladder filling

Increased residual volume, no involuntary detrusor contractions

A 57-year-old man presents with acute-onset nausea and left flank pain. He says his symptoms suddenly started 10 hours ago and have not improved. He describes the pain as severe, colicky, intermittent, and localized to the left flank. The patient denies any fever, chills, or dysuria. His past medical history is significant for nephrolithiasis, incidentally diagnosed 10 months ago on a routine ultrasound, for which he has not been treated. His family history is unremarkable. The patient is afebrile, and his vital signs are within normal limits. On physical examination, he is writhing in pain and moaning. Severe left costovertebral angle tenderness is noted. Gross hematuria is present on urinalysis. A non-contrast CT of the abdomen and pelvis reveals a 12-mm obstructing calculus at the left ureterovesical junction. Initial management, consisting of IV fluid resuscitation, antiemetics, and analgesia, is administered. Which of the following is the best next step in the management of this patient?

Percutaneous nephrostolithotomy (PCNL)

Extracorporeal shockwave lithotripsy (ESWL)

Four hours after undergoing an abdominal hysterectomy, a 43-year-old woman is evaluated in the post-anesthesia care unit because she has only had a urine output of 5 mL of blue-tinged urine since surgery. The operation went smoothly and ureter patency was checked via retrograde injection of methylene blue dye mixed with saline through the Foley catheter. She received 2.4 L of crystalloid fluids intraoperatively and urine output was 1.2 L. She had a history of fibroids with painful and heavy menses. She is otherwise healthy. She underwent 2 cesarean sections 8 and 5 years ago, respectively. Her temperature is 37.4°C (99.3°F), pulse is 75/min, respirations are 16/min, and blood pressure is 122/76 mm Hg. She appears comfortable. Cardiopulmonary examination shows no abnormalities. There is a midline surgical incision with clean and dry dressings. Her abdomen is soft and mildly distended in the lower quadrants. Her bladder is slightly palpable. Extremities are warm and well perfused, and capillary refill is brisk. Laboratory studies show: Leukocyte count 8,300/mm3 Hemoglobin 10.3 g/dL Hematocrit 31% Platelet count 250,000/mm3 Serum _Na+ 140 mEq/L _K+ 4.2 mEq/L _HCO3+ 26 mEq/L _Urea nitrogen 26 mg/dL _Creatinine 1.0 mg/dL Urine _Blood 1+ _WBC none _Protein negative _RBC none _RBC casts none A bladder scan shows 250 mL of retained urine. Which of the following is the next best step in the evaluation of this patient?

Return to the operating room for emergency surgery

Perform ultrasound of the kidneys

Administer 20 mg of IV furosemide

Administer bolus 500 mL of Lactated Ringers

A 33-year-old man is brought to the emergency department 20 minutes after losing control over his bicycle and colliding with a parked car. The handlebar of the bicycle hit his lower abdomen. On arrival, he is alert and oriented. His pulse is 90/min, respirations are 17/min and blood pressure is 110/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. The pupils are equal and reactive to light. There are multiple bruises over his chest and lower extremities. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. There is no pelvic instability. Rectal examination is unremarkable. A complete blood count, prothrombin time, and serum concentrations of glucose, creatinine, and electrolytes are within the reference range. Urine dipstick is mildly positive for blood. Microscopic examination of the urine shows 20 RBCs/hpf. Which of the following is the most appropriate next step in management?

CT scan of the abdomen and pelvis

A 65-year-old African American man presents for follow-up examination with a 6-month history of urinary hesitancy, weak stream, and terminal dribbling, which is refractory to a combination therapy of finasteride and tamsulosin. The patient’s past medical history is otherwise unremarkable. His father and brother were diagnosed with prostate cancer at the age of 55 years. His vital signs are within normal limits. The patient has a normal anal sphincter tone and a bulbocavernosus muscle reflex. Digital rectal exam (DRE) reveals a prostate size equivalent to 2 finger pads with a hard nodule and without fluctuance or tenderness. Serum prostate-specific antigen (PSA) level is 5 ng/mL. Which of the following investigations is most likely to establish a definitive diagnosis?

Magnetic resonance imaging (MRI)

Cystoscopy and urethroscopy for USMLE Step 2 CK: High-Yield Surgery Lessons

🔭 Scoping It Out

Cystourethroscopy: Direct endoscopic visualization of the urethra, prostatic urethra (males), ureteric orifices, and bladder.
Key Indications:
- Diagnostic: Gross/microscopic hematuria, recurrent UTIs, bladder cancer surveillance, voiding symptoms.
- Therapeutic: Biopsy, tumor resection (TURBT), stone removal, stent placement/removal.
Common Complications: Transient hematuria, dysuria, UTI, urinary retention (esp. with BPH).

Scope Selection:

Feature	Flexible Cystoscopy	Rigid Cystoscopy
Setting	Outpatient, office-based	Operating Room (OR)
Anesthesia	Local (lidocaine jelly)	General or spinal
Primary Use	Diagnostic	Therapeutic
Channel Size	Smaller	Larger (for instruments)

Cystoscopy: Male and Female Urethra & Bladder Anatomy

🧐 Clinical Manifestations - The 'Why' We Peek

Key indication is evaluating the source of bleeding or obstruction.

Diagnostic & Surveillance
- Bladder Cancer: Initial diagnosis (biopsy) and routine surveillance for recurrence.
- Recurrent UTIs: Evaluate for anatomical causes (stones, diverticula, fistulas).
- Obstructive/Irritative LUTS: Investigate unclear etiology (stricture, BPH complications).
Therapeutic Interventions
- Stent Management: Placement or removal of ureteral stents.
- Stone Removal: Crushing and removing bladder stones (cystolitholapaxy).
- Tumor Resection: Transurethral Resection of Bladder Tumor (TURBT).

⭐ Painless gross hematuria is bladder cancer until proven otherwise, mandating urgent urologic evaluation.

TURBT: Bladder tumor resection and potential recurrence

🗺️ Anatomy - Navigating the Waterworks

A cystoscope follows a specific anatomical path. The male urethra is longer and more complex.

Male: Longer (~20 cm), S-shaped course. Key landmarks for navigation:
- Verumontanum: A crucial mound in the prostatic urethra where ejaculatory ducts open.
- External Sphincter: Located at the membranous urethra; vital for urinary continence.
Female: Short (~4 cm) and straight path, making instrumentation easier but increasing UTI risk.

⭐ The verumontanum is the most critical landmark to orient within the prostatic urethra. The external sphincter lies just distal to its apex, a "no-go" zone to prevent incontinence during TURP.

⚠️ Complications - When Scopes Go Rogue

Infection (UTI/Urosepsis): Most common. Presents with fever, dysuria, urgency. Risk ↑ with pre-existing bacteriuria or obstruction. Prophylactic antibiotics for high-risk patients.
Bleeding (Hematuria): Typically mild and self-resolving. Persistent or gross hematuria may require catheterization and continuous bladder irrigation (CBI).
Trauma & Perforation:
- Urethral Stricture: A late complication from instrumentation trauma.
- Bladder Perforation: Rare but serious. Acute abdominal pain, inability to void. Requires urgent surgical repair.
Urinary Retention: Due to edema, clots, or anesthesia effects.

⭐ Post-cystoscopy fever with rigors and hypotension is a red flag for urosepsis. Obtain cultures and start empiric IV antibiotics immediately before imaging!

⚡ Biggest Takeaways

Gold standard for evaluating gross hematuria and for bladder cancer surveillance.

Provides direct visualization of the urethra and bladder to find tumors, stones, and strictures.

Enables diagnostic biopsies of suspicious lesions and therapeutic interventions like stent placement.

Flexible cystoscopy is a well-tolerated outpatient procedure; rigid cystoscopy is for OR-based interventions.

Most common complication is post-procedure UTI. Hematuria and dysuria are also frequent.

Acute UTI is a major contraindication due to the risk of iatrogenic urosepsis.

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