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The Acute Scrotum 12 Module 2 Department of Urology Medical Student Handbook INDEX Introduction 1 Contact Information 3 Chairman’s Welcome 4 What is Urology? 5 Urology Rotation Overview 8 Online Teaching Videos 10 Required Readings 11 Module 1. The Acute Scrotum 12 Module 2. Adult Urinary Tract Infections (UTI) 22 Module 3. Benign Prostatic Hyperplasia (BPH) 38 Module 4. Erectile Dysfunction (ED) 47 Module 5. Hematuria 56 Module 6. Kidney Stones 64 Module 7. Pediatric Urinary Tract Infections (UTI) 77 Module 8. Prostate Cancer: Screening and Management 88 Module 9. Urinary Incontinence 95 Module 10. Male Infertility 110 Urologic Abbreviations 118 Suggested Readings 119 Evaluation Process 121 Mistreatment/Harassment Policy 122 Research Opportunities 123 INTRODUCTION Hello, and welcome to Urology! You have chosen a great selective during your Surgical and Procedural Care rotation. Most of the students who take this subspecialty course enjoy themselves and learn more than they thought they would when they signed up for it. During your rotation you will meet a group of urologists who are excited about their medical specialty and feel privileged to work in it. Urology is a rapidly evolving technological specialty that requires surgical and diagnostic skills. Watch the video “Why Urology?” for a brief introduction to the field from the American Urological Association (AUA). https://youtu.be/kyvDMz9MEFA Urology at UW Urology is a specialty that treats patients with many different kinds of problems. At the UW you will see: patients with kidney problems including kidney cancer and kidney stones patients with bladder problems such as bladder cancer and urinary incontinence men with prostate cancer men with benign prostatic enlargement and its subsequent symptom of difficult urination (often cared for by urologists as well as primary care physicians) men with erectile dysfunction and male-factor infertility Pediatric Urology patients with an array of congenital problems with the kidneys, bladder, penis and testicles The majority of the patients at UW require surgery, but other patients have problems that only require medication or reassurance. For this reason, you will spend half of your urology rotation in the OR and half with faculty in clinic. The majority of you will not choose a career in Urology so this rotation is based on the AUA National Medical Student Curriculum. The AUA conducted a survey of a broad assortment of physicians around the country and asked, “What do you think every medical student should know about Urology before finishing medical school?” Based on the results, the curriculum includes the 10 core topics and two skills below. 1. Kidney Stones 2. Hematuria 3. Adult UTI’s 4. Pediatric UTI’s 5. The Acute Scrotum 6. Urinary Incontinence 7. Benign Prostatic Hyperplasia (BPH) 8. Prostate Cancer Management 1 9. Prostate Cancer Screening 10. Erectile Dysfunction 11. How to insert a Foley catheter 12. How to perform a digital rectal exam You can find the curriculum here in this handbook as well as at the Department of Urology’s website and on Canvas. In addition, you will find links to two videos which demonstrate the proper technique for Foley catheter insertion in men and women as well as videos that illustrate proper technique for performing female and male genital exams. There are also links to some patient clinical scenarios that are fun and allow you to do more interactive computer-based learning. In addition to learning through participation in the operating room and seeing patients in clinic, there will also be several small group learning sessions with the Urology faculty in the Department. Lastly, portions of the General Surgery Core Discussion sessions are mentored by some of the Urology faculty and cover several of the core topics that the UW Urology faculty and the AUA feel are important for all medical students to learn. Before you start, our Educational Programs Manager, Denise Mussehl, will email you a copy of your schedule with information about where you should be on your first day of the rotation. Denise will meet with you for orientation during the first day or two of your Urology rotation. She will discuss learning objectives, give you a few suggestions and let you know how faculty provide feedback throughout the rotation. You will also meet with the Department Chairman, Dr. Nakada. 2 CONTACT INFORMATION Tracy Downs, MD Professor Urology Medical Student Education Director 3223 MFCB 1685 Highland Avenue Madison, WI 53705-2281 608-263-9534 [email protected] Denise Mussehl, MS Department of Urology Educational Programs Manager 3259 MFCB 1685 Highland Avenue Madison, WI 53705-2281 608-265-2910 [email protected] Stephen Nakada, MD Professor The David T. Uehling Chair in Urology 3241 MFCB 1685 Highland Avenue Madison, WI 53705-2281 608-215-5990 [email protected] 3 Welcome to Urology 1. Discussion content, Dr. Nakada o Intro to rotation o Urinalysis review, be prepared to discuss: . specific gravity . WBCs . RBCs . Squamous cells . Urinary sediment . Micro . Hematuria history taking 2. Feedback, concerns 1. Denise Mussehl, Coordinator 2. Tracy Downs, Director 3. Stephen Nakada, Chairman, 608-215-5990, [email protected] 4 WHAT IS UROLOGY? The following contains excerpts from What Is Urology: Information for Medical Students and Prospective Urology Residents, prepared by the AUA Graduate Medical Education Committee. Urology is a surgical specialty that deals with diseases of the male and female urinary tract and the male reproductive organs. Although urology is classified as a surgical specialty, knowledge of internal medicine, pediatrics, gynecology, and other specialties is required by the urologist because of the wide variety of clinical problems encountered. In recognition of the wide scope of urology, the American Urological Association has identified seven subspecialty areas: 1. Pediatric Urology 2. Urologic Oncology (cancer) 3. Renal Transplantation 4. Male Infertility 5. Calculi (urinary tract stones) 6. Female Urology (urinary incontinence and pelvic outlet relaxation disorders) 7. Neurourology (voiding disorders, urodynamic evaluation of patients and erectile dysfunction or impotence) Historically, the subject, which clearly established the specialty of urology as being distinct from general surgery, was the treatment of obstructive uropathy. This treatment ranges from the correction of obstructing posterior urethral valves or ureteropelvic junction obstruction in the infant to the correction of bladder outlet obstruction from benign prostatic hyperplasia in the older male. Through the decades, we have witnessed a tremendous increase in our general understanding of the diverse functional disorders of urine transport associated with various overt and covert forms of neuromuscular dysfunction. The rapidly evolving discipline of urodynamics has established itself as a major resource in the diagnosis and therapy of such disturbances. Stone disease of the urinary tract has always provided a substantial portion of general urologic practice. The recent introduction of rigid and flexible ureteroscopy has greatly improved the capacity of the urologist to deal with the problem while the management of stones in the kidney has been revolutionized twice in the immediate past: first with the introduction of percutaneous methods for stone disintegration and extraction, and secondly by the application of shockwave lithotripsy. Collectively these techniques have largely rendered open surgical procedures for dealing with kidney and ureteral stones obsolete. These new technologies remain under urological stewardship. In addition, advances in the diagnosis and metabolic management of recurrent nephrolithiasis allow urologists to reduce the risk of recurrent stone formation. 5 Another area of major urologic concern is that of congenital anomalies. The urinary tract is affected by congenital anomalies more than any other organ system. These congenital abnormalities run the gamut from the relatively common problem of cryptorchidism to the complex area of intersexuality. These patients are usually cared for by Pediatric Urologists. Involvement of the urologist in the problems of renal insufficiency and end-stage renal disease has been necessitated by an enormous increase in the number of patients on dialysis and requiring transplantation. In a number of centers, urologists are the prime surgical arm for renal transplantation and, in others, serve as members of the surgical team. This practice has tended to increase the experience of the urologist in vascular surgery, which has been beneficially incorporated into other areas such as renal vascular reconstruction and in the new microvascular surgical procedures performed for certain cases of impotence. The enhanced communication between nephrologist and urologist often leads to involvement in the general area of hypertension and adrenal disorders. The treatment of malignant disease is a very large portion of urologic practice. Some of the most encouraging results in the medical and surgical management of solid tumors have involved genitourinary tumors, namely testis tumors and Wilms tumors. The development of multimodal therapy, in which chemotherapy, radiation therapy, and surgical treatment are used in conjunction, will hopefully improve the results of the treatment of other genitourinary malignancies. Newer diagnostic methods for the detection of prostate cancer have recently emerged and currently the diagnosis and treatment of prostate cancer occupies much of many
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