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168 Cards in this Set

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79 yo with mild bilateral hydronephrosis and minimally elevated Cr (1.5). Diagnosis?
a. Retroperitoneal fibrosis
b. TCC
c. BPH
d. Neurogenic bladder
e. Vesicoureteral reflux
BPH
Postmenopausal woman, 3.5 cm cyst in ovary with very fine thin septation. Appropriate next step:
A. Immediate CT scan
B. 3 month follow up
C. Surgical excision
D. Laparoscopy
E. Nothing
Surgical excision (if sepatations)
Postmenopausal
<5cm and simple - 3mo f/u,6mo x2, then 1yr
>5cm or complex at any size - laproscopy and excision

Premenopausal
<2.5cm and simple - physiologic
>2.5cm-10cm (simple or complex) - 6wk f/u x2
>10cm - laproscopy and excision
65 yo man has a hypoechoic, painless lesion involving his testis (and epididymis). Dx?
a. lymphoma
b. seminoma
c. epididymo-orchitis
d. yolk sac tumor
e. teratoma
f. dysgerminoma
Lymphoma
-Bilateral, solid, hypoechoic mass on US
-Hypervascular on color Doppler imaging
-Painless scrotal mass
Yolk sac/teratoma - 1st decade,
Choriocarcinoma - 2nd + 3rd decade,
Embryonal cell ca - 3rd decade,
Seminoma - 4th decade,
Lymphoma - 60 yrs average
35-year-old female has bilateral symmetric echogenic renal cortices. What is the likely etiology?
a. Chronic glomerulonephritis
b. Hyperparathyroidism
c. Hyperthryoidism
d. Renal tubular acidosis
e. Acute tubular necrosis
Acute cortical necrosis (first)
Chronic glomerulonephritis (second)

"COAG":
-Cortical Necrosis (Pregnancy, Shock, Infection, Toxins),
-Oxalosis,
-Alport syndrome/AIDS nephropathy,
-Glomerulonephritis (chronic)

CECT: ↑ attenuation of medulla and subcapsular rim separated by low-density cortical zone of necrosis
-Usually extensive and bilateral
33-year-old woman with acute renal failure from cortical necrosis after severe antepartum hemorrhage. Contrast-enhanced axial CT image shows lack of enhancement of renal cortex (arrow) with normal renal medulla enhancement. Note slight enhancement of renal capsule (arrowheads).
Medullary nephrocalcinosis
-hyperparathyroidism
-medullary sponge kidney
-hypercalcemic states
-RTA
All of the following demonstrate echogenic renal cortices on ultrasound EXCEPT:
a. Alport’s syndrome
b. Lymphoma
c. Acute pyelonephritis
d. Chronic pyelonephritis
e. HIV nephropathy
f. Nephrocalcinosis
g. Fetal kidneys
Lymphoma, acute pyelonephritis

-Lymphoma: single/multiple anechoic/hypoechoic masses
-Acute pyelonephritis: in most cases, US appear normal
LEAST likely associated with bladder diverticulum:
a. Secondary to schistosomiasis
b. Some are congenital
c. Bladder outlet obstruction
d. Increased risk of malignancy
e. Calculi may form
Secondary to cystic schistosomiasis (not associated with bladder diverticula)

Schistosomiasis
-causes bladder wall calcifications
-risk factor for SCC
-not associated with bladder diverticula
35 yo infertile female on recomb HCG therapy w/ enlarged ovaries with enlarged peripheral cysts, ascites, and bilateral pleural effusion? Diagnosis?
a. Ovarian hyperstimulation syndrome (OHSS)
b. PCOS
c. Metastatic ovarian cancer
d. Meig's syndrome
Ovarian hyperstimulation syndrome (OHSS)

-frequent iatrogenic complication of ovulation induction with hMG, hCG

-ovarian cysts > 10cm pathognomonic given Hx of HCG

Meig's syndrome
-Ovarian fibroma, ascites, and pleural effusion
Which is associated with Meigs syndrome?
a. Ovarian fibroma
b. Peritoneal calcification
c. Pseudomyxoma peritonei
d. Ovarian virilizing tumor
e. Unilateral left pleural effusion
Ovarian fibroma

-solid ovarian tumor, ascites, and pleural effusion
-elderly women
TRUE about ovarian torsion?
a. Doppler flow excludes torsion
b. More common on left than right
c. Torsed ovary is enlarged
d. Most commonly in malignancy
e. Most commonly in older, postmenopausal women
(Torsed) ovary is enlarged

-Torsion is not excluded by presence of Doppler flow
-R:L torsion is 3:2 due to protective effects of sigmoid mesocolon on the left
-Most common in women during fertile years
30 yo F, HSG shows an enlarged, distorted, irregular uterine cavity (pedunculated lesion in endometrial cavity). Most likely:
a. intrauterine pregnancy
b. endometrial polyp
c. Ashermann’s syndrome
d. intramural leiomyoma (fibroid)
e. hematoma/blood clot
f. endometrial cancer
g. endometrial hyperplasia
Intramural leiomyoma (fibroid)

-Endometrial polyp causes smooth filling defect on HSG
-Asherman's symdrome - intrauterine cavitary adhesions caused by post traumatic/post surgical etiologies
-Endometrial polyp causes smooth filling defect on HSG
MR: low T1, low T2 polypoid pendunculated lesion in the endometrial cavity. Most likely:
a) leiomyoma
b) adenomyosis
c) endometrial polyp
d) endometrial hyperplasia
e) endometrial cancer
Leiomyoma

-sharply marginated masses of low T1 and T2 signal intensity relative to myometrium. Areas of high T2 may represent cystic degeneration.
-DDx of ovarian fibroma

Endometrial polyps
-slightly lower T2 relative to normal endometrium
-diffuse or focal thickening of the endometrial stripe

Endometrial carcinoma
-evidence of myometrial invasion

Adenomyosis
-T1 and T2 high SI foci correspond to small areas of hemorrhage
-JZ thickness > 8-12 mm

Endometrial hyperplasia
-diffuse thickening of the endometrial stripe on T2
Prenatal US shows round, hypoechoic mass (cyst) in upper pole of one of the kidneys. Most likely represents:
A. Obstructed upper pole in a duplicated collecting system
B. ARPKD
C. ADPKD
D. Multicytic dysplastic kidney
E. Wilms' tumor
Obstructed upper pole moeity in a duplicated collecting system

-85% obey Weigert-Meyer rule: Upper pole ureter inserts medial and caudal to lower pole ureter

-Most commonly, upper pole ureter is ectopic and obstructed usually ending in a ureterocele, and lower pole ureter refluxes

-"Drooping lily" sign: Hydronephrosis and ↓ function of obstructed upper pole → downward displacement of lower pole calyces
Unilateral:
MCDK
UPJ obstruction

Bilateral:
ARPKD
ADPKD
Prenatal US shows round, hypoechoic mass (cyst) in upper pole of one of the kidneys. Most likely represents:
A. Obstructed upper pole in a duplicated collecting system
B. ARPKD
C. ADPKD
D. Multicytic dysplastic kidney
E. Wilms' tumor
Obstructed upper pole moeity in a duplicated collecting system

-85% obey Weigert-Meyer rule: Upper pole ureter inserts medial and caudal to lower pole ureter

-Most commonly, upper pole ureter is ectopic and obstructed usually ending in a ureterocele, and lower pole ureter refluxes

-"Drooping lily" sign: Hydronephrosis and ↓ function of obstructed upper pole → downward displacement of lower pole calyces
Unilateral:
MCDK
UPJ obstruction

Bilateral:
ARPKD
ADPKD
bladder outlet obstruction (PUV)

Wilms'
-echogenic or echogenic with discrete holes corresponding to cystic necrosis
HSG contraindicated in:
a. acute PID
b. rectal, vaginal bleeding
c. synechiae
d. infertility
Acute pelvic inflammatory disease

Contraindications:
1. Possible pregnancy.
2. Abnormal uterine bleeding, abnormal last menstrual period (rule out pregnancy).
3. Acute pelvic inflammatory disease.
4. Recent curettage or active genital tract infection.
5. Nontoxic goiter.
6. Endemic iodine deficiency.
7. Present metformin use.
Synechiae
-Asherman's syndrome (intrauterine adhesions)
Absolute contraindication for sonohysterogram:
A) Synechia (adhesions)
B) Vaginal bleeding
C) Abnormal Pap smear result
D) Active PID/endometritis
E) Infertility
F) Recurrent abortions
Active PID/Endometritis

Contraindications:
1. Active PID with abdominal tenderness or palpable mass.
2. Recent uterine/tubal surgery
3. Active uterine bleeding.
4. Pregnancy (schedule exam before ovulation to avoid early pregnancy).

Sonohysterogram/
hysterosonography
-used to investigate uterine abnormalities in women who experience infertility or multiple miscarriages
-evaluating unexplained vaginal bleeding
TRUE about hydrosonography?
a) used to evaluate cause of endometrial thickening
b) best done transabdominally
c) uses iodinated contrast
d) best performed during secretory phase of cycle
e) not to be done post menopausal
Used to evaluate cause of endometrial thickening
TRUE in regards to RUG for man with a suspected stricture:
a. Drip contrast in by gravity
b. Insert catheter under fluoroscopic guidance
c. Obtain oblique spot views
d. Overhead views with complete distention of the urethra
e. Post gonococcal strictures are always short
Obtain oblique spot views

front to back
-penile, bulbar, membarnous, prostatic
-veromonatum involves distal bulbar and membranous

place a nonlubricated 8F or 10F urethral catheter into the fossa navicularis and inflate the balloon with 1-3 mL of sterile water until the balloon occludes the urethral lumen
Sickle cell (trait) is at risk for which renal malignancy?
a. renal medullary carcinoma
b. renal cell carcinoma
c. transitional cell carcinoma
d. justglomeruular apparatus tumor
e. angiomyolipoma
Renal medullary carcinoma

-infiltrating renal neoplasm arising from the collecting tubules of the renal medulla
-< 40 yrs
-high association with sickle cell trait
-indistinguishable from other infiltrating renal neoplasms
Empty right renal fossa on US. 3 cm cystic structure on right side between bladder and prostate gland. What is cyst?
a. Congenital absence of kidney
b. Chronic reflux
c. Horseshoe kidney
d. Seminal vesicle cyst
e. Crossed-fused ectopia
f. Pelvic kidney
Cyst is a seminal vesicle cyst, associated with (ipsilateral) congenital absence of kidney

-characterized by an absent kidney, absent ureter and seminal vesicle (between bladder and the prostate gland)
-results from failure of the metanephric bud to form
Man with seminal vesicle cyst. What is associated finding?
a) ipsilateral renal duplication
b) ipsilateral renal agenesis
c) horseshoe kidney
d) ipsilateral cryptorchidism
e) increased risk for testicular ca
(Ipsilateral) renal agenesis

CONGENITAL seminal vesicle cysts
1. ectopic insertion of ipsilateral ureter (92%)
2. ipsilateral renal agenesis/dysgenesis (80%)
3. duplication of collecting system (8%).

ACQUIRED
to ADPCKD (bilateral sv cysts), invasive bladder CA, infxn
HIV nephropathy distinguished from other causes of renal insufficiency by which finding?
a. Bilateral enlarged kidneys (size)
b. Increased cortical echogenicity
c. Scarring
d. Hydronephrosis
e. Doppler flow
Bilateral enlarged kidneys (size)

-both increased size and echogenicity (increased echogenicity is more sensitive but enlargement is more specific)

More than 90% of patients with HIVAN are black, with 50% having a history of injection drug use.
LEAST likely to be associated with Wilms tumor:
A. Horseshoe kidney
B. Nephroblastomatosis
C. Hereditary aniridia
D.Beckwith-Weidemann syndme
E. Hemihypertrophy
F. Genital anomalies
HEREDITARY aniridia

Most cases of Wilms tumor are not hereditary

Genetic syndromes that predispose to Wilms tumor :

-Beckwith-Wiedemann syndrome (macroglossia, gigantism, and umbilical hernia); -Hemihypertrophy;
-Sporadic aniridia (NOTE: Not HEREDITARY aniridia)
-Wilms tumor, aniridia, genitourinary malformations, and mental retardation (WAGR syndrome)

Nephroblastomatosis is persistent rests of nephrogenic cells within the renal parenchyma and is a precursor of Wilms' tumor
To dx nephroblastomatosis, get:
a. Contrast CT
b. US
c. Renal cortical scintigraphy
d. Gallium scan
Contrast CT

-Homogeneous multifocal ovoid or subcapsular rind-like renal masses
-have potential for malignant transformation into Wilms’
Ideal CT phase for detecting renal mass?
a. Precontrast
b. Arterial phase
c. Corticomedullary phase
d. Nephrographic phase
e. Delayed phase
Nephrogenic phase

Arterial phase (early corticomedullary phase): optimal imaging of renal arterial anatomy (donor nephrectomy)

Corticomedullary phase (CMP) - best phase to assess tumor extension into renal vein

Nephrographic phase (NP): Optimal detection, maximum diagnostic confidence for small renal masses

Excretory phase (EP): helpful for central masses or suspected transitional cell carcinoma
Man with lung cancer and an adrenal mass. Precontrast 26 HU, post contrast 50 HU, delayed 30 HU. Most likely?
a. Metastasis
b. Myelolipoma
c. Adenoma
d. Pheochromocytoma
Adenoma

Mets washout is more prolonged than with adenomas
-50% washout is specific for adenoma
-<50% washout indication of atypical adenoma or met
-HU<30 on 10min delayed - adenoma
MR of adrenal gland in patient with small cell lung cancer, in and out of phase images both show hypointensity. Diagnosis?
a. Metastasis
b. Adenoma
c. Pheochromocytoma
d. Myelolipoma
Metastasis

In/opposed phase imaging has been shown to have a mean signal loss on the out-of-phase imaging of 36% for adenomas, while the mean signal loss for metastases was only 5%.
Obstructive ureteral stone on noncontrast CT diagnosed by:
a. Soft tissue rim sign
b. Comet tail sign
c. Perinephric hematoma
d. Increased density of the obstructed kidney
Soft tissue rim sign

Comet tail sign is one of the criteria necessary for the diagnosis of rounded ateletasis, along with adjacent pleural thickening, volume loss, and a rounded peripheral lesion
Most common risk factor for placenta accreta (percreta)?
a. Prior Caeserian section
b. Prior vaginal delivery
c. DES
d. Multiple gestations
e. Gestational diabetes
f. Placenta previa
Prior Caeserian section

-attachment of the placenta to the uterine wall (decidua) such that the chorionic villi invade abnormally into the myometrium

-Placenta Accreta - chorionic villi in contact with myometrium (80% of cases)
-Increta - chorionic villi invade into myometrium (15% of cases)
-Placenta Percreta - chorionic villi invade into serosa (5% of cases)
TRUE about ectopic ureterocele:
a. More common in boys than girls
b. More common on the left side
c. Almost always associated with a duplicated collecting system
d. Never associated with reflux when inserted near bladder neck
More common on the left side

20% are in single non-duplicated systems (equal M:F)
80% are in duplicated systems, usually upper pole moiety more frequently in girls
Ectopic ureter insertion in a boy most likely to be seen with:
A. Ectopic kidney
B. Duplicated collecting system
C. Hydronephrosis
D. Polycystic kidneys
Duplicated collecting system

When there is duplication of the collecting system, the upper pole moiety inserts ectopically (usually inferior and medial) and obstructs, while the lower pole moiety inserts orthotopically and refluxes

remaining choices are less frequently associated with ectopic ureter
TRUE regarding a duplicated collecting system:
A. the upper ureter inserts caudally relative to lower ureter and is more prone to reflux
B. the upper ureter inserts caudally relative to lower ureter and is more prone to obstruction
C. the lower ureter inserts caudally relative to upper ureter and is more prone to obstruction
D. the lower ureter commonly demonstrates a ureterocele which makes upper pole reflux
The upper ureter inserts caudally relative to the lower ureter and is more prone to obstruction

Upper pole obstructs, lower pole refluxes.

Females may present with continuous dribbling due to the ectopic ureter.

This does not occur in males, because the ectopic insertion is proximal to the external sphincter.
2 days post renal transplant, patient develops flank pain, hematuria. US reveals reversal of diastolic flow of segmental renal artery. Dx?
a. Renal artery stenosis
b. ATN
c. Acute rejection
d. Renal vein thrombosis
Renal vein thrombosis

RVT
-plateau-like reversal of diastolic arterial flow

ATN
-increased RI values
-transient enlargement of the transplant kidney

RAS
-increased velocity > 200cm/s,
-marked tardus-parvus waveform, -2:1 ratio between peak stenotic and poststenotic velocities

acute rejection
-presents several weeks after transplant
-enlarged edematous kidneys, -decreased cortical echogenicity (edema),
-can have increased RI and reversal of diastolic flow.
6 hrs post renal transplant with decreased urine output. US shows reversal of flow in segmental renal artery:
a) Renal Vein Thrombosis
b) Hyperacute rejection
c) ATN
Acute tubular necrosis

-Reversal of flow is seen in ATN, RVT, and rejection. ATN demonstrates transient enlargement of transplant and transient increase in resistive index.
-Reversed flow should be considered a sign of renal vein thrombosis if “holodiastolic” – throughout diastole.
12 hrs (3 days) post renal transplant with swollen/edematous kidneys and mildly increased RI. Cause?
a. ATN
b. renal vein thrombosis
c. RAS
d. cyclosporine toxicity
e. rejection
Acute tubular necrosis

-most common immediate post-transplant complication is ATN which manifests as renal edema and mildly increased RI
-Elevated resistive index (RI > 0.7) on US
-resolves over the first two weeks post transplant
-acutely rejecting kidney may also appear swollen and with elevated RI but the time course is different
Parvus et tardus waveform in renal hilar artery. Diagnosis?
a. renal vein thrombosis
b. distal renal artery stenosis
c. proximal renal artery stenosis
d. rejection
e. AV fistula
Proximal renal artery stenosis

-slowed systolic upstroke and a delayed time to peak systole

-RI will be lower in renal artery stenosis

-stenosis is proximal to where you see the waveform

-Pharmacologic manipulation with captopril may enhance waveform abnormalities in patients with renal artery stenosis.
Tardus-parvus waveform can be specific in setting of what?
A. Renal artery stenosis after administration of captopril
B. The elderly patient
C. A calcified renal artery
D. Diabetic Patient
Renal artery stenosis after administration of captopril

Pharmacologic manipulation with captopril may enhance waveform abnormalities in patients with renal artery stenosis.
Would NOT cause increased RIs in a renal transplant?
A. acute rejection
B. cyclosporine toxicity
C. acute obstruction
D. renal artery stenosis
E. pyelonephritis
F. ATN
G. hydronephrosis
H. AVF
Renal artery stenosis or AVF (do NOT give increased resistive index)

Causes of elevated resistive indices:

Parenchymal: acute rejection, acute tubular necrosis,
pyelonephritis

Vascular: renal vein thrombosis, hypotension

Urological: ureteral obstruction

Technical: graft compression
RI of .9 in a segmental renal artery s/p transplant is most consistent with:
a. Renal vein thrombosis
b. Acute rejection
c. Cyclosporin toxicity
d. Acute tubular necrosis
Acute rejection (the answer could be different depending on time frame)

Doppler US shows initial decrease in resistive index (RI) then increase in RI to >.8. >.9

ATN occurs within 72 hours of transplantation. There may be a transient increase in RI.
Postmenopausal bleeding. Endovaginal US reveals 4 mm endometrial stripe. Diagnosis?
a. Endometrial atrophy
b. Endometrial cancer
c. Endometrial hyperplasia
d. Endometrial polyp
e. Leiomyoma
Endometrial atrophy

Endometrial atrophy is the most common cause of bleeding in a post-menopausal woman with an endometrial stripe < 5mm.

> 5mm, then DDx includes carcinoma, hyperplasia, polyp, tamoxifen-related endometrial changes, metastatic carcinoma such as from ovary, cervix, fallopian tube, leukemia
Post-menopausal bleeding, not on HRT. When would you biopsy the endometrium?
a. 5 mm
b. 3 mm
c. 7 mm
5 mm

Postmenopausal women should have a double layer thickness less than 5 mm

on tamoxifen therapy are allowed a normal thickness up to 8 mm.

On a sonohysterogram, the single layer thickness should be normally less than 3 mm
NOT a cause of endometrial thickening postmenopause?
a. Endometrial polyp
b. Tamoxifen
c. Endometrial cancer
d. Adenomyosis
Adeno

-thickens the junctional zone, not the endometriummyosis

-most commonly in pre-menopausal women.

-Endometrial thickness varies in menstruating women from 4 mm in the early proliferative phase to 13 mm in the late secretory phase.
Most common cause of postmenopausal bleeding:
a. Endometrial polyps,
b. Endometrial hyperplasia
c. Endometrial cancer
d. Endometrial atrophy
Endometrial atrophy (of the answer choices)

Postmenousal bleeding:
-Exogenous estrogen (30%),
-Endometrial atrophy/vaginitis (30%),
-Endometrial cancer (15%),
-Endometrial or cervical polyps (10%),
-Endometrial hyperplasia (5%)
TRUE regarding imaging of endometrial stripe in post menopausal female?
A. measurement should begin along periphery of hypoechoic regions around endometrial stripe
B. measurement is most accurate in the coronal plane
C. tamoxifen causes endometrial thickening, cystic change
D. fluid in the endometrial canal commonly indicates malignancy
Tamoxifen can result in endometral thickening and cystic change

-best imaged in the midline sagittal plane

-hypoechoic region surrounding the endometrium is the myometrium and should NOT be included in the endometrial measurement

-small amount of fluid in the endometrial cavity is normal in asymptomatic patients

-Tamoxifen therapy causes cystic changes with thickening of the endometrium and increases the womans risk for endometrial cancer, hyperplasia, and polyps
All are associated with adenomyosis EXCEPT:
a) sharply defined margins
b) small foci of increased T2
c) generally low T2 signal
d) can have focal thickening of junctional zone
e) can have diffuse thickening of the junctional zone
Sharply defined margins (NOT associated)

-thickened junctional zone of adenomyosis can be focal or diffuse

-typically shows low T2 signal intensity; however, small cystic areas can be present which will appear bright on T2
Specific for adenomyosis on US:
a Heterogenous myometrium
b Focal mass
c Widened subendometrial halo
d Subendometrial cystic regions
Subendometrial cystic regions

-subendometrial cystic regions on US is diagnostic of adenomyosis

-widened subendometrial halo = widened junctional zone is for the MRI appearance of adenomyosis
TRUE regarding adenomyosis?
a. typical low T1 & foci of high T2
b. local excision
c. easy to differentiate from fibroid on US
Typically low T1 and foci of high T2

-T2: the junctional zone (inner layer of myometrium that normally appears as a dark band surrounding the endometrium on T2 is thickened (>12 mm).
TRUE regarding adenomyosis?
a. Hysterosalpingography is the diagnostic test of choice
b. It appears low signal on T2
c. Local resection best treatment
d. Endometrial tissue in the adnexa
e. Rarely mistaken for leiomyoma on hysterosalpingography
It appears low signal on T2 weighted images

-T2: the junctional zone (inner layer of myometrium that normally appears as a dark band surrounding the endometrium on T2 is thickened (>12 mm).

-Small T2 bright foci correspond to hemorrhage

-MR is modality of choice

-treatment is hysterectomy
FALSE regarding adenomyosis?
a. more common in nulliparous women
b. can have normal US appearance
c. can be mistaken for a fibroid
d. a result of invagination of the decidua basalis (ectopic decidua basalis in myometrium)
e. can be diffuse or focal
More common in nulliparous women (FALSE)

-in multiparous women >30 years during mestrual life

-Most lesions are microscopic and not seen by US

-clinically and sonographically difficult to distinguish from a fibroid

-an invasion of the myometrium by the endometrium
FALSE regarding adenomyosis:
a. Difficult to differentiate from leiomyomas on ultrasound
b. Decreased T2 signal intensity relative to the endometrium
c. Best diagnosed with HSG
d. Decidua basalis is found in the myometrium
e. Common adnexal mass
Best diagnosed with HSG and Common adnexal mass (BOTH ARE FALSE)

Best diagnosed with MRI
Urethral cancer associated with:
a. ureter cystica
b. ureteral malacoplakia
c. bladder cancer
d. ureteral polyp
Bladder cancer

-hx of bladder cancer have an increased risk of urethral cancer

-most common type of urethral malignancy is squamous-cell cancer

-SCC occurs primarily in the bulbomembranous and penile regions

-occurs in the prostatic urethra

-TCC is the second most common urethral malignancy
Ureteritis cystica (UC) or cystic pyeloureteritis
-characterized by multiple cysts and filling defects in the ureter and renal pelvis, visualized during IVP
-benign inflammatory pathology

Malacoplakia
-single or multiple smooth, rounded, filling defects of the bladder, but this is non-specific
-Differentiation of malacoplakia from transitional cell carcinoma and other tumors requires cystoscopy and biopsy
-benign, self-limiting course
-with antibiotics and endoscopic resection and fulguration
Regarding the penile urethra:
a. stricture at penoscrotal junction most commonly due to catheterization
b. most common cancer is adenocarcinoma
c. anterior urethra defined as the distance to penoscrotal junction
d. gonococcal strictures are short segment
Stricture at the penoscrotal junction is most commonly due to catheterization; penoscrotal junction is where most catheter induced trauma occurs

-Catheterization is the most common cause of anterior urethral injury

-Occurs at membranous urethra or penoscrotal junction

causes of urethral strictures:
1. Urethritis (non-infectious).
2. Urethritis (infectious - typically gonococcus, chlamydia, ureaplasma urealyticum, or less commonly, TB).
3. Gonococcal structures typically are at the proximal bulbar urethra

Urethral cancers

SCC (bulbar or membranous) > TC (prostatic)

Adenocarcinomas - most common malignancy to occur in a urethral diverticulum

Association exists between TCC of the prostatic urethra and previous transurethral resection of bladder CA.
TRUE about diverticula in the female urethra?
a) diverticula need marsupalization
b) diverticula located posteriorly
c) develops after long term catheterization
d) causes stress incontinence
Diverticula located posteriorly

-Urethral diverticula occur more often in females than males

-rarely congenital

-occur when periurethral glands become infected and obstructed

-occur in the distal 1/3 of the urethra

-occur POSTERIORLY in the urethra, causing indentation of the ANTERIOR wall of the vagina

-Classically present with postvoid dribbling, dysuria and dyspareunia

-surgical resection not required

-many tx options including marsupialization (creation of permanent opening)
FALSE regarding urethral diverticulum in females?
a. They are most often congenital
b. Can pres w/ stress incontinence
c. Treated by marsupialization
d. They are usually located off the posterior wall of the urethra
They are most often congenital

-Urethral diverticula occur more often in females than males

-rarely congenital

-occur when periurethral glands become infected and obstructed

-occur in the distal 1/3 of the urethra

-occur POSTERIORLY in the urethra, causing indentation of the ANTERIOR wall of the vagina

-Classically present with postvoid dribbling, dysuria and dyspareunia
Which part due congenital urethral diverticulum occurs in?
a. Prostatic urethra (posterior urethral valves cause dilation)
b. Membranous
c. Bulbous
d. Trigone of the bladder
Bulbous

Congenital urethral diverticulum -occurs only in males
-arises from the ventral surface of the anterior urethra

urethral diverticulum in females is acquired
NOT associated with renal cysts:
a. Neurofibromatosis
b. Tuberous Sclerosis
c. Von Hippel Lindau
d. Hydatid cyst
e. Chronic dialysis
Neurofibromatosis

multiple cortical renal cysts:
VHL,
TS,
Meckel-Gruber syndrome,
Jeune syndrome,
Zellweger syndrome (cerebrohepatorenal syndrome), Conradi syndrome, (chondrodysplasia punctata), trisomy 13,
Turner syndrome,
Dandy-Walker syndrome
Associated with unilateral multicystic dysplastic kidney:
a. contralateral UPJ obstruction
b. contralateral ectopic ureter
c. contralateral ureterocele

versus

Associated with contralateral kidney in MCDK?
a. UPJ obstruction
b. reflux
Contralateral VUR, then contralateral UPJ obstruction

A non-functional kidney, replaced by multiple cysts and dysplastic tissue

MCDK is the second most common abdominal mass in a neonate

Up to 40% of patients with MCDK have contralateral abnormality

Ureteropelvic junction obstruction (UPJO) and vesicoureteral reflux are most common
MOST likely to present as unilateral renal cystic disease (renal process) (in a child):
a. multicystic dysplastic kidney
b. AD polycystic kidney disease
c. AR polycystic kidney disease
d. acquired cysts from dialysis
e. medullary cystic disease
Multicystic dysplastic kidney (MCDK)

A non-functional kidney, replaced by multiple cysts and dysplastic tissue

MCDK is the second most common abdominal mass in a neonate

Up to 40% of patients with MCDK have contralateral abnormality

Ureteropelvic junction obstruction (UPJO) and vesicoureteral reflux are most common
Prenatal US, fetus has oligohy-dramnios, bilateral renal cysts. Most likely diagnosis?
a. AR polycystic kidney disease
b. AD polycystic kidney disease
c. medullary cystic disease
d. multicystic dysplastic kidney
e. congenital nephrosis
Multicystic dysplastic kidney

ADPKD and medullary cystic disease aren’t routinely seen in the infant.

ARPKD is seen in the fetus but does not have discernable cysts, rather the kidneys are large and echogenic with through-transmission. May have oligohydramnios depending on renal function.

If the contralateral kidney is normal in MCDK, bladder seen, and AFI normal, then good prognosis.
Underlying etiology of MCDK:
a. medullary cystic disease
b. medullary sponge kidney
c. obstruction
Obstruction

results from occlusion (severe UPJ obstruction) of fetal ureters before 10 weeks of gestation.

Absent/atretic renal vessels and collecting system.

MCDK involute in time.
Medullary cystic disease

Group of related diseases with progressive renal tubular atrophy, secondary glomerulosclerosis, and medullary cyst formation

Small, smooth kidneys with cysts in medulla

Juvenile and adult forms
In utero pelvico-infundibular atresia (stenosis) will lead to:
a. Infantile polycystic kidney dis
b. Adult polycystic kidney disease
c. Multi-locular cystic nephroma
d. Multicystic dysplastic kidneys
e. Renal agenesis
Multicystic dysplastic kidneys

Results from occlusion (severe UPJ) of the ureter in the fetus before 10 weeks gestation

Absent/atretic renal vessels and collecting system
Location of Cowper's glands?
A. (posterior)membranous urethra
B. anterior bulbous urethra
C. posterior bulbous urethra
C. posterior prostatic urethra
D. penile urethra
Posterior membranous urethra

Located in the urogenital diaphragm (membranous urethra)
Most specific for ARPKD on US:
A. Small kidneys
B. Hydronephrosis
C. Increased echogenicity
D. Decreased echoenicity
E. Multicystic
Increased echogenicity

Best diagnostic clue: Enlarged, hyperechoic kidneys

Large kidneys of uniformly high signal intensity on T2WI

Renal enlargement may not occur until mid 2nd trimester

Oligohydramnios

Musculoskeletal abnormalities
Oligohydramnios limits movement → contractures

Fetal bladder not visible
Most specific for ARPKD on US:
A. Small kidneys
B. Hydronephrosis
C. Increased echogenicity
D. Decreased echoenicity
E. Multicystic
Increased echogenicity

Best diagnostic clue: Enlarged, hyperechoic kidneys

Large kidneys of uniformly high signal intensity on T2WI

Renal enlargement may not occur until mid 2nd trimester

Oligohydramnios

Musculoskeletal abnormalities
Oligohydramnios limits movement → contractures

Fetal bladder not visible

Liver disease is present in every patient with ARPKD

Most common clinical manifestion of congenital hepatic fibrosis is portal hypertension

less severe the renal findings, the more severe the hepatic findings
NOT associated with (VHL) von Hippel-Lindau syndrome?
a. angiomyolipoma
b. renal cysts
c. renal cell cancer
Angiomyolipoma (NOT associated)

AML is associated with tuberous sclerosis

VHL
retinal and central nervous system (CNS) hemangioblastomas, pheochromocytomas,
multiple cysts of the pancreas and kidneys
high potential for malignant transformation of renal cysts into carcinoma.
NOT a cause of persistent (delayed) nephrogram?
a. Acute pyelonephritis
b. RVT
c. ATN
d. RAS
e. Hypotension
f. Contrast induced nephropathy
g. Acute ureteral obstruction
Common

Obstruction (TCC, RCC, etc)
RVT
RAS
ATN
Hypotension (shock)
Pyelonephritis

Less common
Contrast-Induced nephropathy
Corpus luteal cyst ruptures at:
a. 1 cm
b. 2 cm
c. 3 cm
3 cm

Rupture of these ovarian cysts occurs more often on the right side, during intercourse and during the later days of the menstrual cycle

Oral contraceptive therapy has been known to markedly reduce the risk of the formation of the functional ovarian cysts.
Ovarian follicle rupture at:
A. 10mm
B. 15mm
C. 20mm
D. 25mm
20 mm

Mean diameter at rupture is 20-23 mm
Asherman's syndrome (or synechiae) is best diagnosed by:
a. HSG
b. US
Hysteroscopy is best (not an answer choice); HSG second best

intrauterine adhesions secondary to severe inflammation

causes infertility
Most common cause of testicular metastasis?
a. Lymphoma
b. Renal
c. Stomach
Lymphoma

most common malignancies that metastasize to the testicle

Lymphoma
leukemia
melanoma
CT finding of cystic renal mass most suggestive of malignancy:
a. Iso-attenuation on contrast CT to renal parenchyma.
b. Density on CE CT of 60 HU
c. Changes from 40 to 69HU from pre- to post-contrast (Enhancement on CECT)
d. Rim calcifications
e. Cystic w/ internal septation
Change from 40 to 69 HU after contrast (Enhancement on CECT)

Enhancement is considered present when lesion components increased by at least 10 HU.
On BE, endometriosis is similar to?
a. Intraperitoneal mets
b. GIST tumor
c. Metastatic melanoma
d. Lipoma
Intraperitoneal mets

Endometriosis:
Rectosigmoid colon is the most common site of gastrointestinal involvement

Rectosigmoid endometriosis usually manifests on double contrast as extrinsic mass effect flattening, tethering, and/or spiculation of the anterior border of the rectosigmoid colon
20 year old female with 2 cm ovarian lesion on CT with no septation, calcifications, or nodules. Management?
a. No follow up
b. Follow up CT in 3 months
c. Follow up CTvin 6 months
d. Excise
e. MRI
No follow up

Premenopausal
<2.5cm and simple - physiologic
>2.5cm-10cm (simple or complex) - 6wk f/u x2
>10cm - laproscopy and excision
NOT associated with increased echogenicity of infant renal (medullary) pyramids?
a. Fanconi anemia
b. Prune belly syndrome
c. RTA
d. Lasix (Furosemide)
e. Hypercalciuria
f. Williams'
Prune belly syndrome (NOT associated)

DDx of echogenic renal pyramids in children
nephrocalcinosis (most common)
Lasix (furosemide) (common)
renal tubular acidosis (common)
Infant/neonate with echogenic cortex in kidneys, most likely?
a. ATN
b. RAS
c. Furosemide toxicity
d. Hypercalciuria
e. RVT
Furosemide toxicity

long-time furosemide therapy in premature infants and neonates with CHF results in hypercalciuria
What is the genetic material in a partial molar pregnancy?
a. Triploid
b. Trisomy 21
c. Trisomy 22
d. 45X
Triploid

all partial moles are triploid
What causes juxtaglomerular apparatus to respond?
a. Decreased renal arterial pressure
b. High potassium sensed by juxtaglomerular apparatus
Decreased renal arterial pressure

Juxtaglomerular cells (JG cells, granular cells) are site of renin secretion

JG cells are found in the afferent arterioles of the glomerulus act as an intra-renal pressure sensor

Lowered pressure leads to secretion of renin which acts to increase systemic blood pressure via the renin-angiotensin system
TRUE about early IUP?
a. MSD increases by 3mm per day
b. Can routinely see gestational sac at bHCG 2000 (Intrauterine GS is consistently seen w/ HCG of 2000)
c. bHCG doubles every 24 hrs
d. HCG doubles until 4 wks gestat
Can routinely see gestational sac at bHCG 2000

MSD increases by 1.1 mm/day

When bHCG >1800, can see 100% of GS’s on transabdominal US

Can see 100% of GS’s on TV when bHCG is >1000

bHCG doubles every 2-3 days for first 60 days of pregnancy
By which gestational age does corpus luteum cyst of pregnancy resolve:
a. 5 weeks
b. 10 weeks
c. 15 weeks
d. 20 weeks
20 weeks

A corpus luteum cyst may be present until 16 weeks but should regress thereafter, owing to the assumption of progesterone synthesis by the placenta
Aldosteronoma has decreased:
a) renin
b) sodium
c) blood pressure
d) ST segments
e) mood
Renin levels are decreased

In aldosteronoma, renin decreases; sodium and BP increase

remember that aldosteronoma cannot be diagnosed with an MIBG scan since it is an adrenal cortex tumor

MIBG is good for adrenal medullary & neural crest tumors

Conn’s syndrome is autonomous hypersecretion of aldosterone with associated sodium retention, HTN, K+ wasting, and low renin
TRUE about aldosteronoma?
a. Found in medulla
b. Histologically, cannot differentiate from a cortisol tumor
c. low serum renin levels
d. low serum sodium/salt wasting
e. arises from adrenal medulla
f. multiple
Low serum renin levels versus Histologically, cannot differentiate from a cortisol tumor

Conn’s syndrome is autonomous hypersecretion of aldosterone with associated sodium retention, HTN, K+ wasting, and low renin
HTN, hypokalemia refractory to ACE inhibitors. Diagnosis?
a. Adrenal adenoma
b. Pheochromocytoma
c. Fibromuscular dysplasia
Adrenal adenoma

Conn syndrome is due to a solitary adrenocortical adenoma, causing primary hyperaldosteronism,
subsequent hypertension, hypernatremia,
hypokalemia,
nephrogenic diabetes insipidus, metabolic alkalosis,
suppression of plasma renin levels (low serum renin level).
FALSE about Conn’s syndrome:
a. Hypernatremia
b. Hypokalemia
c. Hypertension
d. Increased renin
e. Increased aldosterone
Increased renin (NOT seen)
TRUE regarding multilocular cystic nephroma:
a) protrudes into collecting system
b) cysts connect to each other
c) central stellate region
d) homogenous enhancement
e) spreads to renal hilar nodes
Protrudes into collecting system

MLCN: cluster of noncommunicating cysts that have a tendency to protrude into the collecting system.
Most common renal mass in 2 month-old (3 week old):
a. Mesoblastic nephroma
b. Wilms'
c. Rhabdoid tumor
Mesoblastic nephroma

Congenital mesoblastic nephroma (CMN) is the most common renal neoplasm in neonates.

well circumscribed, hypoechoic mass without posterior acoustic enhancement

Mesoblastic nephroma is histologically similar to, and often radiologically indistinguishable from, Wilms tumor. Wilms tumor present at peak ages of 2-3 years.
FALSE about mesoblastic nephroma?
a) can invade adjacent structures
b) is malignant
c) commonest neonatal renal mass
d) can diagnose on prenatal US
Is malignant (FALSE)

Most common solid renal neoplasm in neonate.

Infiltrative growth with no real cleavage plane.

No venous extension.

No invasion of collecting system.
FALSE about mesoblastic nephroma:
a. excellent prognosis post-resection
b. similar to Wilm's on ultrasound
c. cystic with fine septations
d. unlikely to calcify
Has a cystic appearance with fine septations (FALSE)

well circumscribed, hypoechoic mass without posterior acoustic enhancement

usually solid but may produce multiple cystic spaces

Most common renal neoplasm in neonate.

Excision usually is performed for diagnosis rather than cure because radiographically these tumors can mimic Wilm’s tumor.

Excellent prognosis—cure is usually achieved by nephrectomy
What type of kidney stone do you get in bowel resection?
a. calcium phosphate
b. uric acid
c. calcium oxalate
Calcium oxalate

Short bowel syndrome, which may result from surgery in the small intestine, is marked by the inability of the intestines to absorb fat and nutrients properly (malabsorption). In such cases, calcium may bind to unabsorbed fat instead of to oxalates. This leaves excess oxalate, which is absorbed by the intestine and excreted into the kidney.
Most common cause of UPJ obstruction?
a) crossing vessel
b) abnormal insertion of ureter
c) intrinsic ureteral abnormality (abnormal intrinsic muscle)
d) duplication
Intrinsic ureteral abnormality or abnormal intrinsic muscle

Intrinsic ureteral motility abnormalities account for 80% of UPJ obstructions

crossing vessel is the cause of UPJ obstruction in 20% of patients
60 yo diabetic has intrascrotal air and soft tissue inflammation with normal testicles on CT. Most likely diagnosis is:
a) Fournier’s gangrene
b) Epididymitis
c) Torsion
d) TB
Fournier's gangrene

Fournier’s is polymicrobial necrotizing fasciitis

occurs in diabetics, surgical emergency.
TRUE about renal lymphoma?
a) get posterior acoustic enhancement and hypoechoic mass
Get posterior acoustic enhancement and hypoechoic mass

Kidneys most common extranodal site of lymphoma.

US: increased through transmission, decreased echoes, loss of renal sinus.
Match following about prostate:
A. Transitional zone
B. Peripheral zone
C. Central zone
1. Most frequent site of carcinoma
2. Largest glandular zone
3. BPH
1-B, 2-B, 3- A

BPH occurs in the transitional zone.
Most likely origin of prostate CA
a. Peripheral zone
b. Central zone
c. Periurethral prostate
d. Transitional zone
Peripheral zone

70% cancers in peripheral zone. The peripheral zone is the largest glandular zone.
Prostate tissue removed during TURP for BPH is most likely from which zone?
a. Peripheral zone
b. Periurethral zone
c. Central zone
d. Transitional zone
Transitional zone

In BPH, tissue hypertrophy occurs in the transitional zone (this compresses the CZ and thins the PZ).
Coronal and sagittal images of prostate gland labeled. Match:
a. majority of carcinomas occur
b. where BPH occurs
c. where prostatitis occurs
Prostate cancer: peripheral zone. BPH: transitional zone. Prostatitis diffusely involves the gland.
Patient s/p TURP, which area is likely to contain stricture?
a. bladder neck /prostatic urethra
b. membranous urethra
c. penile urethra
d. bulbous urethra
e. fossa navicularis
Bladder neck/prostatic urethra

BPH usually involves a small grouping of ductal tissue near the central portion of the prostatic urethra near the internal sphincter.

As the transition zone expands, it can comprise 95% of the prostate volume, compressing the other zones.
Most common cause of a dilated prostatic urethra:
a. Detrusor dysreflexia
b. Detrusor-sphincter dysinigeria
c. Prostatitis
d. Transurethral resection of the prostate (TURP)
e. Previous Foley catheter
Transurethral resection of the prostate (TURP)

The prostatic urethra is generally patulous following a TURP, which removes predominantly the transitional zone of the prostate.

This enlargement is secondary to a loss of prostatic mass, not downstream obstruction.

Detrusor sphincter dyssynergia results in simultaneous detrusor and sphincter contraction, and thus, a functional outlet obstruction,
resulting in dilatation of the prostatic urethra.
NOT a cause of a small thickened bladder:
a) Diabetes w/ neurogenic bladder
b) Detrusor spinchter dysenergia
c) Cyclophosphamide cystitis
d) Radiation cystitis
e) Spinal cord injury
Diabetes with neurogenic bladder (NOT small thickened bladder)

Detrusor sphincter dysenergia is associated with a Christmas tree bladder.

Cyclophosphamide (Cytoxan) causes hemorrhagic cystitis and a small thick bladder.

Neurogenic bladder results in muscular hypertrophy.

Small bladder also from scarring from tuberculosis, schistosomiasis, other varieties of cystitis, or partial bladder resection.

Diabetic neuropathy results in detrusor areflexia. Neurologic damage is focused on the sacral reflex arc, with a loss of perception of bladder distention. Bladder just continues to fill until urine just overflow dribbles. Small, thin–walled, increased capacity.
TRUE regarding ureteral pseudodiverticulosis in men:
a) associated with TB
b) most commonly in the distal portion of the ureter
c) congenital
d) may be malignant
May be malignant

There is an association with transitional cell malignancy in 30% of patients with ureteral pseudodiverticulosis.

This makes close follow-up prudent. Predominately upper and mid ureter.
Which are TRUE regarding paraovarian cysts?
a. are Mullerian (versus Wolffian) duct remnant
b. torsion does not occur
c. shows hormonal change
d. represent 10% of adnexal cysts
e. confused with fibroids
Respresent 10% of all adnexal masses

They may undergo torsion and rupture.

They show no cyclic changes in response to hormonal stimulation.
They do not change with menstrual cycle like ovarian cysts.

They are of mesonephric (Wolffian) origin.

They can look just like functional ovarian cysts.

They occur usually in the broad ligament at the lateral edge of vagina and uterus.

They occur in the third to fourth decade.
T/F about a paraovarian cyst:
a Located in the broad ligament
b Comprise 10% of ovarian cysts
c Remnant of the Wolffian duct
d Remnant of the Müellerian duct
e. Respond to hormonal therapy
A. True.
B. False ?adnexal cysts
C. True
D. False
E. False

Paraovarian cysts are remnants of the Wolffian duct (= mesonephric duct).
Precocious puberty in a girl, non-tender (painless) ovarian mass, most likely:
a) Granulosa cell tumor
b) Brenner tumor
c) Krukenberg tumor
Granulosa cell tumor

Adnexal masses in children, generally: 60% are germ cell tumors, higher incidence of malignancy than adults

Granulosa cell tumor-juvenile: 80% of ovarian neoplasms arising before age 20

most prepubertal patients present with sexual precocity due to excessive estrogen production
All associated with bladder (wall) calcifications, EXCEPT:
a. Transitional cell carcinoma
b. Schistosomiasis
c. Alkaline encrustation cystitis
d. Cyclophosphomide cystitis
e. Malakoplakia
f. TB
Malakoplakia (no bladder calcifications)

Pneumonic for bladder wall calcifications = SCRITT. Schistosomiasis. Cytoxan. Radiation. Interstitial cystitis. TB. TCC.

Malacoplakia is considered by most to be an intramural ureteral lesion that occurs secondary to chronic urinary tract infection. The plaque-like, intramural lesions are caused by build-up of defective macrophages and are not premalignant.
NOT considered premalignant?
a. Cystitis Glandularis
b. Leukoplakia
c. Cystitis cystica
d. Malakoplakia
Malakoplakia

Cystitis cystica = cystitis glandularis, premalignant

Leukoplakia = keratinizing squamous metaplasia – result of chronic infection and stones, premalignant
Associated with salpingitis isthmica nodosa (SIN)?
a. Endometriosis
b. Hydrosalpinx (could be...)
c. Ovarian cancer
d. Uterine synechiae
Endometriosis

SIN = diverticulosis of the Fallopian tubes - inflammation in the isthmic portion of the Fallopian tube.

Salpingitis isthmica nodosa is associated with:
#1 Pelvic Inflammatory Disease (in 89% of PID cases);
#2 Endometriosis (28%);
#3 other causes (TB, congenital disorders).
Female patient with a smooth lobulated impression on the inferior aspect of the bladder (base of bladder) has post-void urinary dribbling. Diagnosis?
a. Urethral diverticulum
b. Ectopic ureter
c. Ureterocele
d. Ureteral diverticulum
e. Fistula
Urethral diverticulum

Urethral diverticulum (6x more common in black women).

Congenital ones occur in males and are second to posterior urethral valves as the most common cause of urethral obstruction in male infants.

Acquired ones (aka pseudodiverticulum) present in adults, often due to infection and abscess formation in female parauretheral glands which decompress into the urethra.

These, if large enough, can elevate the base of the bladder (the “female prostate” sign).

They predispose to infection and stone formation. Frequency, dysuria, dyspareunia, and postvoid dribbling are common symptoms.
Most frequent complication of Crohn’s disease in the GU tract:
a) Rectovesical fistula
b) Stones
c) TCC
d) RCC
e) Obstruction
Stones

In patients with Crohn’s disease, water and electrolyte losses in diarrhea and malabsorption cause changes in the composition of urine leading to stone formation.

Oxalate stones are the most common

Uric acid stones are also common, particularly in patients with ileostomies.

The occurrence of nephrolithiasis is roughly proportional to the amount of distal small bowel involvement or resection and degree of malabsorption.
Which disease produces bilateral small echogenic kidneys:
A. Multicystic dysplastic kidney
B. Medullary cystic disease
C. AD polycystic kidney disease
D. AR polycystic kidney disease
E. HIV nephropathy
Medullary cystic disease

Medullary cystic disease (nephronophthis) is a salt wasting nephropathy.

Get normal /small kidneys with thin cortex.

US demonstrates small kidneys, diffuse increased parenchymal echogenicity due to microscopic cysts.
LEAST likely to result in drop metastasis to pelvis simulating (stage III) ovarian carcinoma:
a. Stomach
b. Colon
c. Breast
d. Gallbladder
e. Renal cell carcinoma
Renal cell carcinoma (LEAST likely)

The most common primary sites of ovarian metastases are tumors of the breast and gastrointestinal tract.

The term Krukenberg tumor should be reserved for those tumors containing the typical mucin-secreting “signet ring” cells, usually of gastric or colonic origin.

Endometrial carcinoma frequently metastases to the ovary

Lymphoma may involve the ovary, usually in a diffuse, disseminated form that is frequently bilateral.
TRUE regarding prostate?
a. Increased signal on T2
b. Higher PSA associated with CA than BPH in biopsy specimen
c. Hypoechoic lesions on US are usually malignant
d. CA can appear echogenic on US
e. Use of prostate coils for MR is contraindicated after TR biopsy
Higher PSA associated with CA than BPH in biopsy specimen

Prostate cancer elevates PSA 10x more than does BPH (per gram of tissue)

Prostate cancer appears hypoechoic, 70%, hyperechoic or mixed, 30%, on ultrasound.

Other hypoechoic lesions in the prostate are prostatitis, atrophy, fibrosis, infarct, BPH.

Not all patients with malignancy have elevated levels.

Regarding post TR biopsy, endorectal coils can be used although imaging is typically done 3 weeks post procedure to avoid artifacts.
LEAST likely cause of inter-menstrual bleeding?
A. adenomyosis
B. endometrial polyp
C. endometrial cancer
D. cervical cancer
E. ovulation
Ovulation (LEAST likely)

Bleeding can be seen in cervical cancer, endometrial carcinoma, adenomyosis, and polyps.
CT w/ and w/o contrast shows a 3 cm well- defined mass intervening a bifid renal system displacing calyces, enhances same as cortex. Diagnosis:
a. normal kidney tissue (column of Bertin)
b. suspicious for RCC
c. oncocytoma
d. TCC
e. Juxtaglomular tumor
Normal kidney tissue

Large column of Bertin represents a large septum/cloison of Bertin or focal cortical hyperplasia or benign cortical rest or focal renal hypertrophy.

usually in the presence of partial or complete duplication (bifid system).

location is between the upper and interpolar portion

usually a mass <3 cm

mass is continuous with renal cortex with enhancement pattern and echogenicity similar to renal cortex
Most common site of congenital male urethral obstruction (posterior urethral valves)?
A. penile urethra
B. bulbous urethra
C. prostatic uretrha
D. trigone
E. internal sphincter
F. membranous urethra
Prostatic urethra

Posterior urethral valves occur almost always in boys, and is the most common cause in infants for urinary obstruction.

they are seen usually adjacent to the distal verum montanum, in the distal prostatic urethra.

Three types of posterior urethral valve:
Type I - #1, fold from inferior verumontanum distal (which is in the prostatic urethra) to membranous urethra
Fetal US shows (bilateral) urinary tract obstruction. In male, most common obstruction:
a. membranous urethra
b. prostatic urethra
c. bulbous urethra
d. bladder outlet obstruction
e. ureteropelvic junction
f. ureterovesicular junction
Prostatic urethra

Posterior urethral valves are congenital thick folds of mucous membrane located in the posterior urethra (prostatic + membranous portion) distal to verumontanum. Most common cause of urinary tract obstruction and leading cause of end stage renal disease among boys
Gas in bladder wall in uncontrolled diabetic. Cause?
A. E. coli
B. trauma
C. Staph
D. Candida
E. coli

Emphysematous cystitis is a rare clinical entity, in which bacteria produce gas in the bladder wall and lumen.

In the setting of a diabetic patient. E. Coli is listed as the number one cause
Most characteristic of an adrenal adenoma on MR chemical shift imaging?
A. isointense to paraspinal muscles on in phase and hypointense on out of phase
B. isointense to paraspinal muscles on both in and out of phase
Isointense to paraspinal muscles on in-phase imaging and hypointense on out-of-phase imaging

With adrenocortical adenoma, you get marked hypointensity compared with spleen (which is similar intensity to paraspinous muscles) on out-of-phase GRE images.

With adenomas you may also see India ink effect characteristic black lines outlining interface between organ and adjacent fat due to chemical shift artifact.
Associated w/ squamous cell CA:
a) renal TB
b) urate nephropathy
c) analgesics
d) infected staghorn calculus
Infected staghorn calculus

Chronic inflammation, such as in chronic Schistosomiasis, staghorn calculus, recurrent infections, bladder diverticula and bladder extrophy, is established risk mainly in SCC but also in TCC.

Squamous cell cancer of the renal pelvis is frequently associated with leukoplakia or chronic irritation from stones or UTI. Leukoplakia is pre-malignant.

Analgesics predispose to transitional cell carcinoma (TCC).
Pt w/ hx of chronic obstruction secondary to stones now presents with mass in left renal pelvis:
a. squamous cell CA
b. transitional cell CA
c. fungus ball
d. stones
Squamous cell carcinoma

patients with bladder stone disease are prone to develop squamous cell carcinoma secondary to chronic inflammation
Patient with known analgesic abuse in renal pelvis. Diagnosis?
a. TCC
b. Fungus
c. Clot (hematoma)
d. SCCa
TCC

Analgesic nephropathy is related to excessive ingestion of phenacetin, acetaminophen, aspirin or NSAIDS in combination or alone, resulting in interstitial nephritis and papillary necrosis.

Transitional cell carcinoma demonstrates an increased prevalence in this patient population.

If sloughed papillae were one of the choices, it would be the correct answer as this occurs much more commonly than TCC in this disease entity.
Man with extraperitoneal bladder rupture. CT shows contrast extending to perineum. Which injury is associated:
a) urethral injury
b) pubic bone fracture
c) vertebral body fracture
Pubic bone fracture

Extraperitoneal bladder rupture is commonly associated with pubic ramus fracture from lateral compression force.
Retrograde urethrogram performed on a 45 year old male demonstrates filling of the glands of Littre and stricture of bulbous urethra. Etiology:
a. Penile urethral fracture
b. Blunt trauma
c. Previous gonococcal infection
d. Radiation
e. Previous instrumentation
Previous gonococcal infection

Glands of Littre are multiple small glands which line the penile urethra.

If there is contrast filling of the glands with a retrograde urethrogram, there is urethritis.

The glands may become infected with gonorrheal urethritis.

Gonorrhea accounts for approximately 40% of male urethral strictures in North America.

Infection starts in the glands of Littre and moves proximally.
Most common cause of colovesicular fistula:
a. Crohn’s disease
b. Diverticulitis
c. Ulcerative colitis
d. Cystitis cystica
e. Trauma
Diverticulitis

Vesicoenteric fistula were most frequently attributable to diverticulitis (52% of vesicoenteric fistulas), Crohn's disease (18%), carcinoma of the colon (11%)
NOT a germ cell tumor:
a. Seminoma
b. Teratoma
c. Choriocarcinoma
d. Embryonal cell tumor
e. Leydig cell tumor
Leydig cell tumor

Germ cell tumors = “SECTY”= Seminoma, Embryonal cell carcinoma, Choriocarcinoma, Teratoma, Yolk sac.

Leydig cell tumor is stromal cell origin
Excretory urogram demonstrate unilateral swelling of the interureteric ridge. Etiology:
A. calculus
B. carcinoma
C. seminal vesiculitis
D. prostatitis
E. cystitis
Calculus


Stone impacted at the ureterovesical junction and comments on the “edema in the right side of the interureteric ridge”, which is normally less than 3 mm in thickness.
Discriminate mature ovarian teratoma from cystadenocarcinoma:
a A very echogenic focus within it.
b Peripheral increased Dopplerflow
c Homogeneously increased echogenicity of cyst contents
A very echogenic focus within it

A highly echogenic nodular focus with dirty acoustic shadowing (the “tip of the iceberg” sign) is
characteristic of a cystic teratoma.
Renal mass is most likely to be mistaken for a cyst on US?
a. Reninoma
b. Lymphoma
c. Mets
d. AML
e. TCC
Lymphoma

Lymphoma – kidney most common site of extranodal lymphoma. On US, single or multiple anechoic/hypoechoic masses, which may show increased thru transmission.

Reninoma – rare, benign tumor arising from JG cells. 50% < 21 years old. US: echogenic mass with areas of necrosis/hemorrhage.

AML – benign mesenchymal tumor of the kidney, should contain hyperechoic fat/hemorrhage. Assoc with TS.

TCC – US: bulky hypoechoic (similar to renal parenchyma)/hyperechoic mass lesion. Infiltrative without disrupting renal contour.
Most sensistive method for diagnosis of bladder cancer in a patient with microscopic hematuria and positive UA?
A. CT
B. US
C. retrograde cystography
D. cystoscopy
E. pelvic MRI
Cystoscopy

TCC of the bladder is the most common urinary tract neoplasm.

MRI is used for staging and is better than CT to evaluate bladder wall invasion depth.
FALSE regarding ovarian cysts in postmenopausal women:
a. Most are < 3 cm
b. Most are benign
c. Simple cysts are seen in 50%
d. Cysts are often caused by hormone replacement therapy
e. Mural nodules should prompt further work-up for carcinoma
Simple cysts are seen in up to 50% (FALSE)

Asymptomatic simple adnexal cysts may be seen in 20-30% of postmenopausal women.

up to 40% ofwomen on HRT have ovarian cysts (vs. only 20-30% of post-menopausal women w/o HRT).


a cyst with a mural nodule in a peri-/post-menopausal woman raises the suspicion for clear cell carcinoma of the ovary.

Postmenopausal cysts: The incidence of malignancy in simple cysts <3cm is low. US follow-up is recommended for cysts <3cm. If >3cm or change in size of a smaller lesion, must perform surgery.
TRUE regarding ovarian cyst in postmenopausal women:
a. Simple cysts < 5cm are most likely benign
b. Uncommon, seen in only 5%
Simple cysts < 5 cm are most likely benign

Most cysts are less than 3 cm in greatest dimension.

Most simple cysts in postmenopausal ovaries <5cm are not likely malignant.

Asymptomatic simple adnexal cysts may be seen in 20-30% of postmenopausal women.
Average size of postmenopausal ovarian cyst?
a. 2 cm
b. 3 cm
c. 4 cm
d. 5 cm
3 cm

Most cysts are less than 3.5 (some say 3.0) cm in greatest dimension.

Most simple cysts in postmenopausal ovaries <5cm are not likely malignant.
Female s/p gynecological surgery. VCUG reveals bladder with a smooth peak pointing to the right SI joint. Diagnosis?
A. psoas hitch
B. lymphadenopathy
C. adhesions from prior surgery
D. tumor recurrence
Psoas hitch

Both a ‘psoas hitch procedure’ and a ‘Baoli flap’ are ureteral substitution procedures. Of the pics I saw, the Baoli is more beak like, while the psoas hitch is more of an eccentric dome of bladder.
NOT cause of papillary necrosis:
a. regular NSAID use
b. diabetes
c. oxalosis
d. renal vein thrombosis
e. TB
f. sickle cell
g. hepatic cirrhosis
Oxalosis (not a POSTCARD)

Analgesic abuse, diabetes, and sickle cell are the most common causes.

POSTCARD includes causes of papillary necrosis: Pyelonephritis, Obstruction, Sickle cell disease, Tuberculosis, Cirrhosis, Analgesic abuse, Renal vein thrombosis, and Diabetes mellitus
Tamoxifen increases the risk of which of the following cancers:
a. endometrial
b. ovarian
c. breast
d. colon
e. pancreatic
Endometrial

Tamoxifen is associated with increased incidence of endometrial hyperplasia, polyps and cancer.
Renal excretion of iodinated contrast is primarily from:
a. glomerular filtration
b. tubular secretion
c. both glomerular and tubular
d. tubular secretion, resorption
Primarily from glomerular filtration
Pelvic floor support is NOT provided by:
A. pubococcygeus
B. iliococcygeus
C. urogenital diaphragm
D. sup levator fascia
E. inf levator fascia
Urogenital diaphragm
What is the lowest density stone?
a. indinavir
b. xanthine
c. cystine
d. urate
Indinavir

Indinavir sulfate is a protease inhibitor used to treat patients with HIV. Stones radiolucent on either abdominal radiographs or CT.

Cystine stones are not as dense as calcium stones.

Xanthine stones are relatively radiolucent because their density is similar to uric acid stones.

Uric acid stones account for the majority of “lucent” stones. However, they are still sufficiently dense to be easily seen on CT.
Testicular US in 12 y/o boy with delayed (chronic) testicular torsion. Which is LEAST likely?
a. Increased extratesticular flow
b. Decreased intratesticular flow
c. Testicular microlithiasis
d. Heterogeneous testicle
e. Hydrocele
Testicular microlithiasis

Late findings with torsion are absent or decreased testicular flow, late peritesticular inflammation & hypervascularity, testicular enlargement and heterogeneity, eventual atrophy and a reactive hydrocele; enlarged echogenic epididymis.

Microlithiasis has no known underlying disease but has been associated with cryptorchidism & malignancy. May see a reversal of diastolic flow or loss of diastolic flow in cases of threatened torsion or early torsion.
MOST commonly associated with horseshoe kidney?
a. dysplastic cysts
b. infections
c. UPJ obstruction
d. cardiac anomalies
Ureteropelvic junction obstruction

Associated anomalies of horseshoe kidneys (50%): UPJ obstruction (30%), ureteral duplication (10%)

Commonly associated with infections (obstruction, stones, stasis).

If question is NOT associated, answer is dysplastic kidneys.
Most common complication of a urachal cyst in a 20 yo?
A. Carcinoma
B. Infection
C. Bleeding
D. Urinary retention
E. Retained stone
Infection

Urachal cyst is a residual cyst without communication to the bladder or the umbilicus

presents as a tender, swollen mass secondary to infection

the urachus is a structure which connects the dome of the bladder to the anterior abdominal wall at the level of the umbilicus.
Primary megaureter is MOST associated with:
A. Delayed ureteral emptying
B. More common on the right side
C. Cryptorchidism
D. Renal agenesis
Delayed ureteral emptying

Primary megaureter is defined as congenital dilatation of the distal ureter due to functional obstruction.

More common on the left.

More common in males.

Note that the calyces remain sharp

Primary megaureter is NOT associated with Prune Belly Syndrome (separated rectus muscles, megaureters, and cryptorchidism).


Most commonly (95%) an isolated finding
In vesicoureteral reflux, scarring most often occurs where?
a. interpolar region
b. at the poles
c. not related to papillae anatomy
d. dependent on portion of kidneys
At the poles

Reflux nephropathy predominantly affects poles of kidneys secondary to presence of compound calyces.
TRUE regarding cystic disease of the kidney in renal failure?
a. Most cysts > 0.5 cm
b. 25% develop renal cell CA
c. frequency of developing cysts is directly related to number of years of renal failure
d. Typically one kidney involved
The frequency of developing cysts is directly related to number of years with renal failure

Renal cysts occur in approximately 8% of patients at the initiation of dialysis and increase proportional to the duration of dialysis.

This increases to 90% after 5 to 10 years.

Solid tumors also are seen with increased frequency, up to 7%. These solid neoplasms include adenomas, oncocytomas, and adenocarcinomas.
Thrombosed ovarian vein in the postpurpeural stage may appear as all of the following EXCEPT?
a. absent ultrasound flow
b. mass at the junction of the right renal vein and the ovarian vein
c. soft tissue density anterior to the right psoas
d. echolucent linear structure
Mass at the junction of the right renal vein and the ovarian vein (NOT associated)

The right ovarian vein drains directly into the IVC.

However, the thrombus commonly affects the most cephalic portion of the right ovarian vein and can usually be demonstrated sonographically at the junction of the right ovarian vein with the inferior vena cava

- right ovarian vein is involved in 80-90% of cases (retrograde through left ovarian vein in the puerperium protects this side)
- sonography may demonstrate an inflammatory mass lateral to the uterus and anterior to the psoas
- Doppler imaging may demonstrate absence of flow in these veins
- ovarian vein may appear as a tubular, anechoic structure containing echogenic thrombus.

presents on 2nd or 3rd postpartum day
Anatomy of retroperitoneum:
a. right renal artery is posterior to the IVC
Right renal artery is posterior to the IVC
FALSE regarding ureteral jets?
a. occur in 3rd trimester
b. used to prove patency of ureters
c. need to evaluate for 5-10 min
d. used to diagnose obstruction
Need to evaluate for 5-10 minutes (FALSE)

Ureteral jets occur every 1-3 minutes.

Benign hydronephrosis of pregnancy occurs in up to 90% of women in their 3rd trimester, which may make visualization of ureteral jets difficult.

Ureteral jets are absent in the presence of urinary obstruction but are maintained in the presence of nonobstructive hydronephrosis.
55 yo woman with a well defined homogenously enhancing 2.5 cm renal mass which measures 60 HU. Hematuria. Next step:
a. partial nephrectomy
b. NECT (nonenhanced CT)
c. Biopsy
d. Delayed imaging to recheck HU
e. Nothing
f. HMPAO nuc study
Partial nephrectomy

True enhancing masses (>15 HU enhancement) should be treated surgically, whether it is a traditional nephrectomy, or a nephron-sparing procedure.

NECT is essential to assess enhancement.

A hemorrhagic cyst could present as the above described mass. However, it would not enhance (increase >10 HU) on CECT.

DMSA scan would show a photopenic defect in either case and not be able to differentiate between a complex/ hemorrhagic cyst and solid neoplasm. DMSA would be useful in distinguishing a renal pseudotumor from a true mass.
53 year old male with bladder CA with 2 cm left adrenal mass which measures 30 HU. What should be done next?
a. report suspicious for mets
b. recommend biopsy
c. recommend an NP-Iodocholest-eriol nuclear imaging study
d. recommend 6 month follow-up
e. obtain delayed imaging through the level of the adrenals
Obtain delayed imaging through the levels of the adrenals

Unilateral adrenal mass: CT attenuation <0 HU = benign mass, 0-15 HU = probably benign, >15 HU = indeterminate
on 15- minute delayed CECT scan: < 25 HU benign lesion, > 25 HU malignant lesion
50 yo female with bladder CA. CT shows 2.5cm left adrenal mass (-30 HU). Diagnosis
a. metastasis
b. adenoma
c. hyperplasia
d. myelolipoma
Myelolipoma

True fat density (-30 to -90HU)

Adenoma (<10HU)
50 y/o asymptomatic male has small nodular mass in one limb of left adrenal gland. Diagnosis?
a. Adrenal carcinoid
b. Adrenal hyperplasia
c. Pheochromocytoma
d. Metastasis
e. Hyperaldosteronoma
Metastasis (note: adenoma not an answer choice)

A non-functioning adenoma would be the best answer but is not a choice. Metastasis 30% of adrenal masses

Incidental discovery of adrenal mass in 1% of all CT: Mass < 3 cm in diameter is likely (in 87%) benign

Mass > 5 cm in diameter is likely malignant.

Adenoma is the most common cause at 50% of adrenal masses.
Most common cause of focal scarring and pyelonephritis is:
a. pyelotubular backflow
b. pyelolymphatic backflow
c. abscess
d. ruptured fornices
e. focal ischemia
Pyelotubular backflow

Vesico-ureteral reflux and pyelotubular backflow is the most common cause of pyelonephritis.
DDx of hyperechoic kidneys includes all EXCEPT:
a) HIV
b) pyelonephritis
c) infarction
Pyelonephritis

Bilateral echogenic kidneys:
1) Polycyctic kidney disease are diffusely echogenic when cysts small (children)

2) HIV nephropathy, showing a slightly enlarged kidney with diffusely hyperechoic parenchyma

3) Focal infarct shows a wedge of HYPO or HYPER echoic area
Concerning AV fistula in kidney, what is most common cause?
a. blunt trauma
b. biopsy
c. renal cell CA
d. lithotripsy
Biopsy

percutaneous renal biopsy the most common cause

Post Bx #1, ruptured aneurysm or RCC also

Polyarteritis nodosa - frequent small aneurysms which progress to fistulas
Cystitis glandularis is associated with which of the following:
a. pelvic lipomatosis
b. TCC
c. ectopic ureter
d. Crohn's
Pelvic lipomatosis

Pelvic lipomatosis, a non-malignant overgrowth of adipose tissue within the pelvis, causing urinary frequency, low back pain and UTIs.

Cystitis glandularis is an overgrowth of the mucin secreting cells in the bladder wall.
Imaging for Column of Bertin?
a. Technetium
b. DTPA with lasix
c. DTPA with captopril
d. MAG-3
e. DMSA
DMSA

Functional imaging is not the key, cortical imaging is the key. DMSA or Glucoheptonate.
Reasons for functional imaging include: evaluation of scarring and “evaluation for pseudotumor, as seen with a hypertrophied column of Bertin
Reason for lasix in a renal scan?
a. differentiate dilated collecting system and ureters from primary megaureter
b. Elevated creatinine
c. Normal lab values
To differentiate dilated collecting system and ureters from primary megaureter

Lasix administration (20-40 mg IV) 20 minutes into exam allows assessment of renal pelvic clearance with accuracy equal to Whitaker test

which differentiates obstructed from nonobstructed dilated pelvicalyceal system
What cohort has the greatest sensitivity to lasix?
a. patients who are Na+ restricted
Patients who are sodium restricted

e.g elderly, CHF patients etc.
Ureteral prominence of trigone is unilaterally edematous. What is the most likely source?
a. ureterocele
b. unilat seminal vesicle infection
c. BPH
d. UTI
e. recently passed stone
Recently passed stone
Associated with increased risk of bladder carcinoma:
a. Cystitis cystica
b. Cystitis glandularis
c. Malacoplakia
d. Congenital bladder diverticulum
e. Pelvic lipomatosis
Cystitis glandularis

Cystitis glandularis = mucin secreting glandular hypertrophy from repeated bacterial infections, premalignant

Cystitis cystica = multiple serous-filled cysts causing filling defects from repeated bacterial infections

Malakoplakia = uncommon chronic inflammatory response to gram negative infection

Pelvic lipomatosis = nonmalignant overgrowth of adipose tissue
Hutch diverticulum - located just above and lateral to the ureteral orifice, predispose to vesicoureteral reflux, bladder outlet obstruction, associated with neurogenic bladders.
43-yo woman, Cr 1.3, normal IVP. Patient is scheduled for a barium enema next day. Scout film demonstrates bilateral small kidneys with increased density, no contrast in bladder. Dx:
a. Contrast induced renal failure
b. Acute hypotension
c. Acute papillary necrosis
d. Acute cortical necrosis
e. Renal tubular acidosis
Contrast-induce renal failure

Causes of an increasingly dense nephrogram: systemic arterial hypotension, severe renal artery stenosis (unilateral), acute tubular necrosis due to contrast material nephrotoxicity, acute renal vein thrombosis

A delayed, persistent nephrogram at 24 hours has been observed in the majority of patients with contrast nephropathy.
25-yo presents in first trimester with acute unilateral flank pain and hematuria. Diagnostic test:
a. KUB
b. Ultrasound
c. IVP with 2-film technique
d. Helical CT
e. MRI
Ultrasound

US to rule out hydronephrosis or stone.
Uptake on MIBG EXCEPT:
a. Carcinoid
b. Paraganglioma
c. Aldosteronoma
d. Pheochromocytoma
e. Neuroblastoma
Aldosteronoma (no uptake on MIBG scan)

Also remember that aldosteronoma cannot be diagnosed with an MIBG scan since it is an adrenal cortex tumor.

MIBG is good for adrenal medullary & neural crest tumors.
NOT in anterior pararenal space
a. Ascending colon
b. Duodenum
c. Pancreas
d. Adrenal glands
e. Descending colon
Adrenal glands (not in anterior pararenal space)

Anterior pararenal – ascend and descend colon, duo 3rd portion, pancreas
Posterior pararenal – fat
Perirenal – kidneys, adrenals
The most likely finding in a patient with recurrent UTI’s and a high imperforate anus:
a. Rectovesical fistula
b. Rectoureteral fistula
c. Vesicoureteral reflux
d. Neurogenic bladder
Rectoureteral fistula (recalled)
?VUR

Approximately 60% of patients with high or intermediate forms of imperforate anus have some form of associated genitourinary (GU) malformation or vesicoureteral reflux (VUR).

High malformation: male = rectourethral fistula; female = rectovaginal fistula, hydrometrocolpos.

Low malformation: male = anoperineal fistula; female = fistula to lower portion of urethra, vagina, perineum
An oncocytoma is classified as:
a. A renal cell tumor
b. A hamartomatous tumor
c. A sarcomatous tumor
d. An epithelial tumor
e. A neuroendocrine tumor
An epithelial tumor

Oncocytomas are epithelial tumors

A renal oncocytoma is benign tumor of the kidney

Sonography reveals a solid, homogeneous mass indistinguishable from RCC on the basis of echogenicity.

Angiographic features include a spokewheel pattern

Tx is nephrectomy.
On RUG, a filling defect is present midline at level of the veromontanum. Most likely:
a. Urachal cyst
b. Urethral duplication cyst
c. Muellerian duct cyst
d. Wolffian duct cyst

Middle-aged man presents with bladder obstruction. Cystic midline mass in prostate which did not contain sperm. PSA is 0. Most likely diagnosis?
Müllerian duct cyst

Verumontanum = fused end of Müllerian ducts.

The urachus, a fetal tract extending from the bladder dome to the umbilicus, normally has become obliterated by birth. With persistence of the entire urachus, urine will drain from the umbilicus. More commonly, only part of the tract persists and forms either a urachal cyst or a diverticulum of the bladder dome.
Most associated with cryptor-chidism (undescended testis):
a. Leydig cell tumor
b. Seminoma
c. Teratoma
d. Choriocarcinoma
Seminoma

Seminoma is 40-50% of all testicular tumors and most common in undescended

30x increase in undescended testis
Most common risk factor for the development of contrast induced renal failure:
a. pheochromocytoma
b. myeloma
c. pre-existing renal insufficiency
Pre-existing renal insufficiency

An increase in serum creatinine of >25% or to > 2mg/dl within 2 days of receiving contrast material.

Risk factors:
1. Preexisting renal insufficiency (serum creatinine > 1.5 mg/dL).
2. Diabetes mellitus (possibly related to dehydration/hyperuricemia).
3. Dehydration.
4. Cardiovascular disease.
5. Use of diuretics.
6. Advanced age > 70 years.
7. Multiple myeloma (in dehydrated patients).
8. Hypertension.
9. Hyperuricemia /uricosuria
Characteristic of uterus on US:
a. 3 layers day 1-5 of cycle
b. Increased thickness during the secretory phase
c. Thinned in proliferative phase
Increased thickness during the secretory phase

“Between [the end of the menses] and the onset of ovulation, termed the proliferative (estrogen) phase, the stripe becomes thicker, as much as 8 mm, and remains uniformly hyperechoic and distinct… from ovulation until the start of the menses, termed the secretory (progesterone) phase, the endometrium thickens further, typically as much as 15 mm,
Most reliable measurement for cervical incompetence is:
A. Length of the cervix
B. Width of the cervix
C. Caliber of internal (external) os
Length of the cervix