SPEX Exam Urology — Questions and Answers
Question 1: A 55-year-old man presents with fever, chills, dysuria, and a tender, boggy prostate on digital rectal examination. Urinalysis reveals pyuria and bacteriuria. The most appropriate management is:
- Prostate massage to culture expressed secretions
- Trimethoprim-sulfamethoxazole for 3 days
- Hospitalization and IV antibiotics for a minimum of 7 days
- Fluoroquinolone for 4–6 weeks with avoidance of prostate massage (Correct answer)
Correct answer: Fluoroquinolone for 4–6 weeks with avoidance of prostate massage
Acute bacterial prostatitis requires a prolonged antibiotic course (4–6 weeks) due to poor antibiotic penetration into prostatic tissue; fluoroquinolones (ciprofloxacin) achieve the best tissue levels. Prostate massage is absolutely contraindicated in acute prostatitis—it risks bacteremia and sepsis. A 3-day course is adequate only for uncomplicated cystitis in women. IV antibiotics are reserved for urosepsis or inability to tolerate oral therapy.
Question 2: A 40-year-old man presents with sudden-onset severe colicky left flank pain radiating to the groin, nausea, and hematuria. Non-contrast CT shows a 4 mm stone at the ureterovesical junction. The most appropriate initial management is:
- Immediate urologic intervention with ureteroscopy
- Medical expulsive therapy with an alpha-blocker and analgesia (Correct answer)
- Extracorporeal shock wave lithotripsy today
- Surgical ureterolithotomy
Correct answer: Medical expulsive therapy with an alpha-blocker and analgesia
Stones ≤ 5 mm at the UVJ have a >80% spontaneous passage rate. Medical expulsive therapy with an alpha-blocker (tamsulosin) relaxes the distal ureter, accelerating stone passage and reducing pain episodes. NSAIDs and opioids manage pain. Ureteroscopy and ESWL are reserved for stones that fail conservative management, are > 5–10 mm, or cause persistent obstruction, infection, or intractable pain. Ureterolithotomy is rarely required.
Question 3: A 65-year-old man has a PSA of 6.8 ng/mL on routine screening. His PSA was 4.2 ng/mL two years ago. Digital rectal exam reveals a small, smooth prostate. The most appropriate next step is:
- Reassure him that PSA elevation is normal for his age
- Start finasteride to lower PSA before making clinical decisions
- Refer to urology for consideration of prostate biopsy (Correct answer)
- Repeat PSA in 5 years if DRE remains normal
Correct answer: Refer to urology for consideration of prostate biopsy
A PSA rise from 4.2 to 6.8 ng/mL over 2 years represents a PSA velocity of ~1.3 ng/mL/year, exceeding the 0.75 ng/mL/year threshold associated with increased prostate cancer risk. Combined with an absolute PSA above 4.0 ng/mL, urology referral for biopsy discussion (multiparametric MRI ± biopsy) is appropriate. Reassurance is inappropriate without evaluation. Finasteride reduces PSA by ~50% and should not be started to obscure a rising value. A 5-year interval is too long given the rate of rise.
Question 4: A 70-year-old man presents with 3 weeks of painless gross hematuria. He is a former smoker. Urinalysis confirms hematuria without casts or proteinuria. The most important next diagnostic step is:
- Repeat urinalysis in 6 weeks before further workup
- Urine culture and a course of antibiotics empirically
- Cystoscopy and upper tract imaging (CT urogram) (Correct answer)
- PSA level and DRE
Correct answer: Cystoscopy and upper tract imaging (CT urogram)
Painless gross hematuria in a patient over 35, especially a smoker, must be presumed malignant until proven otherwise. Bladder cancer (the most common urologic malignancy in older adults) classically presents with painless gross hematuria. The gold standard evaluation is cystoscopy (to directly visualize the bladder) plus upper tract imaging (CT urogram) to evaluate the kidneys and ureters. Watchful waiting risks missing early-stage cancer. Empiric antibiotics are inappropriate without evidence of infection. PSA/DRE address prostate, not hematuria etiology.
Question 5: A 35-year-old man presents with sudden-onset severe right testicular pain, nausea, and vomiting for 3 hours. The testicle is high-riding with a horizontal lie. Cremasteric reflex is absent on the right. The most appropriate management is:
- Scrotal ultrasound with Doppler to confirm diagnosis before surgery
- Urine culture and empiric antibiotics for epididymo-orchitis
- Immediate surgical exploration without waiting for imaging (Correct answer)
- Manual detorsion followed by urology follow-up in one week
Correct answer: Immediate surgical exploration without waiting for imaging
Testicular torsion is a surgical emergency with a narrow time window: testicular salvage approaches 100% within 6 hours, drops to ~50% at 12 hours, and approaches 0% after 24 hours. The clinical presentation here (high-riding horizontal testicle, absent cremasteric reflex, acute severe pain) is pathognomonic. When clinical suspicion is high, immediate surgical exploration—not imaging—is the priority. Doppler ultrasound is used when the diagnosis is uncertain; delaying surgery to obtain imaging when the diagnosis is clear is the most common error.
Question 6: A 68-year-old man with type 2 diabetes and hypertension complains of erectile dysfunction for 8 months. He is on metformin, lisinopril, and atorvastatin. The FIRST-LINE pharmacologic treatment for his erectile dysfunction is:
- Intracavernosal alprostadil injection
- Testosterone replacement therapy
- A phosphodiesterase type 5 (PDE5) inhibitor such as sildenafil (Correct answer)
- Switch antihypertensive to a beta-blocker
Correct answer: A phosphodiesterase type 5 (PDE5) inhibitor such as sildenafil
PDE5 inhibitors (sildenafil, tadalafil, vardenafil) are the first-line pharmacotherapy for erectile dysfunction of any etiology, including vasculogenic (most common in diabetic, hypertensive men). They enhance nitric-oxide–mediated smooth muscle relaxation in cavernosal tissue. Intracavernosal injections are second-line. Testosterone replacement is indicated only if hypogonadism is confirmed; routine supplementation without low testosterone is inappropriate. Beta-blockers can worsen ED and would not be added here.
SPEX Exam Urology
A 55-year-old man presents with fever, chills, dysuria, and a tender, boggy prostate on digital rectal examination.
Urinalysis reveals pyuria and bacteriuria.
The most appropriate management is: