CURN Mastery Series III: High-Acuity Bladder
Malignancies, Metabolic Stone Cascades, Prostate
Cancer Survivorship, and Neuro-Urologic Incontinence
Syndromes
Target Audience: Experienced urologic nurses / CURN candidates
Difficulty: Mixed (25% Foundational, 55% Application/Scenario, 20% Advanced/Hard)
Section 1: Bladder Disorders (Questions 1–30)
1. A 72-year-old patient with high-risk non-muscle invasive bladder cancer (NMIBC) receives BCG induction. After the
third instillation, he develops high fever (40°C), hypotension, and acute respiratory distress. What is the priority
intervention?
A) Intravesical lidocaine
B) IV ceftriaxone and discharge home
C) Anti-tuberculosis therapy (rifampin, isoniazid, ethambutol) plus corticosteroids
D) Repeat BCG at half dose
Correct Answer: C
Rationale: These are signs of BCG sepsis (disseminated infection). Immediate anti-TB therapy and steroids are life-
saving.
2. A 58-year-old woman with long-term ketamine use presents with severe suprapubic pain, hematuria, and
frequency. Cystoscopy shows a markedly contracted bladder (150 mL capacity) with diffuse inflammation. What is the
most effective long-term surgical option?
A) Augmentation cystoplasty
B) Sacral neuromodulation
C) Intravesical DMSO
D) Urethral dilation
Correct Answer: A
Rationale: Ketamine cystitis causes bladder fibrosis and contraction. Augmentation cystoplasty increases capacity
and reduces pain.
3. A patient with recurrent NMIBC on BCG maintenance develops granulomatous prostatitis on biopsy. He has no
systemic symptoms. What is the appropriate management?
A) Discontinue BCG permanently
B) Treat with 6 months of isoniazid
C) Continue BCG if asymptomatic
D) Perform radical prostatectomy
Correct Answer: C
Rationale: Asymptomatic granulomatous prostatitis is a known benign finding after BCG and not a contraindication
to continuing therapy.
,4. A 66-year-old man with interstitial cystitis has failed oral pentosan polysulfate, amitriptyline, and hydroxyzine. His
cystoscopy reveals a pinpoint bladder (250 mL capacity under anesthesia). What is the next best step?
A) Intravesical BCG
B) Hydrodistention alone
C) Cystectomy with urinary diversion
D) Sacral neuromodulation
Correct Answer: C
Rationale: End-stage IC/BPS with severely reduced capacity and refractory pain may require cystectomy.
Neuromodulation is not effective for end-stage.
5. A patient with orthotopic neobladder after radical cystectomy reports new-onset nocturnal incontinence only.
Urodynamics show a low-compliance neobladder (8 mL/cm H₂O) with no detrusor overactivity. What is the most likely
cause?
A) Sphincter weakness
B) Neobladder overactivity
C) Outlet obstruction
D) Metabolic acidosis
Correct Answer: B
Rationale: Low compliance indicates storage dysfunction; nocturnal incontinence often from neobladder
overactivity. Treat with anticholinergics.
6. A 48-year-old woman with recurrent UTIs (10 in past year) has negative cystoscopy and CT urogram. She is
postmenopausal not using estrogen. What is the most effective preventive therapy?
A) Daily cranberry extract
B) Vaginal estradiol cream
C) Methenamine hippurate
D) Post-coital cephalexin
Correct Answer: B
Rationale: Vaginal estrogen restores lactobacilli, lowers vaginal pH, and reduces UTI recurrence by 50-75%.
7. A patient with spinal cord injury (T6) on intermittent catheterization develops a bladder stone composed of calcium
phosphate. Urine culture is sterile. What is the most likely etiology?
A) Chronic alkaline urine from diet
B) Neurogenic bladder with incomplete emptying
C) Hypercalciuria of immobilization
D) Infection with urease-negative bacteria
Correct Answer: C
Rationale: Immobilization causes bone resorption and hypercalciuria, leading to calcium phosphate stones even
without infection.
8. A 62-year-old with BCG-unresponsive CIS refuses cystectomy. What intravesical agent has the highest response rate
as an alternative?
A) Gemcitabine plus docetaxel
B) Valrubicin
C) Mitomycin C
,D) Interferon-alpha
Correct Answer: A
Rationale: Sequential intravesical gemcitabine and docetaxel has a 2-year disease-free survival of 50-60% in BCG-
unresponsive NMIBC.
9. A patient with neurogenic detrusor overactivity due to multiple sclerosis is on oxybutynin IR 5 mg TID. She develops
severe dry mouth and constipation. What change would most reduce side effects while maintaining efficacy?
A) Switch to oxybutynin patch
B) Add pilocarpine
C) Reduce dose to BID
D) Switch to solifenacin 5 mg
Correct Answer: A
Rationale: Transdermal oxybutynin bypasses first-pass metabolism, reducing dry mouth and constipation
significantly.
10. A 70-year-old with high-grade T1 bladder cancer and CIS undergoes radical cystectomy. Pathology shows pT1N0,
negative margins, and lymphovascular invasion. What is the recommended adjuvant therapy?
A) Observation
B) Adjuvant chemotherapy (gemcitabine + cisplatin)
C) Adjuvant radiotherapy
D) Intravesical BCG via conduit
Correct Answer: B
Rationale: LVI in pT1N0 bladder cancer increases risk of occult metastases; adjuvant chemotherapy improves
survival.
11. A patient with chronic indwelling suprapubic catheter for 8 years develops squamous cell carcinoma of the
bladder. What is the most important risk factor?
A) Chronic inflammation and irritation
B) HPV infection
C) Tobacco use
D) Schistosoma haematobium
Correct Answer: A
Rationale: Chronic indwelling catheter causes squamous metaplasia → dysplasia → squamous cell carcinoma (rare
but well-described).
12. A 44-year-old woman with refractory OAB and PVR 25 mL fails mirabegron and solifenacin. She desires a non-daily
treatment. What third-line option has the lowest risk of permanent retention?
A) Botulinum toxin 100U
B) PTNS (12 weekly sessions)
C) Sacral neuromodulation
D) Percutaneous tibial nerve stimulation
Correct Answer: C
Rationale: Sacral neuromodulation does not cause urinary retention. Botulinum toxin causes transient retention in
15-20%.
13. A patient with interstitial cystitis and Hunner’s lesions undergoes fulguration. Post-op day 3, she reports severe
, pain radiating to the flank. What is the most likely complication?
A) Ureteral orifice injury with obstruction
B) Bladder perforation
C) Urinary tract infection
D) Pelvic hematoma
Correct Answer: A
Rationale: Fulguration near trigone can injure ureteral orifice, causing obstruction and flank pain. CT urogram
needed.
14. A patient on intravesical BCG develops a fever of 38.2°C, fatigue, and malaise 4 hours after instillation. What is the
appropriate next step?
A) Administer acetaminophen and observe
B) Start empiric antibiotics and anti-TB drugs
C) Remove the catheter immediately
D) Instill intravesical lidocaine
Correct Answer: A
Rationale: Low-grade fever (<38.5°C) within hours is common BCG reaction. Acetaminophen and observation. High
fever or hypotension = BCG sepsis.
15. A 75-year-old with Parkinson’s disease and OAB has a PVR of 350 mL and recurrent UTIs. Urodynamics show
detrusor underactivity. What is the safest OAB medication?
A) Oxybutynin
B) Mirabegron
C) Solifenacin
D) Trospium
Correct Answer: B
Rationale: Mirabegron does not worsen detrusor underactivity. Anticholinergics increase PVR and retention risk.
16. A patient with recurrent NMIBC receives BCG induction and then maintenance for 1 year. Surveillance cystoscopy
shows a 5 mm papillary tumor. TURBT reveals Ta low-grade. What is the next step?
A) Repeat BCG induction
B) Observation (no further BCG)
C) Cystectomy
D) Intravesical gemcitabine
Correct Answer: A
Rationale: Low-grade recurrence after BCG maintenance still responds to re-induction BCG.
17. A 62-year-old woman with mixed incontinence and severe prolapse (POP-Q stage 4) undergoes sacrocolpopexy
with concomitant mid-urethral sling. Post-op day 1, she is unable to void and PVR 600 mL. What is the most likely
cause?
A) Sling too tight
B) Post-operative urinary retention (normal)
C) Detrusor areflexia from anesthesia
D) Urethral edema
Correct Answer: B
Malignancies, Metabolic Stone Cascades, Prostate
Cancer Survivorship, and Neuro-Urologic Incontinence
Syndromes
Target Audience: Experienced urologic nurses / CURN candidates
Difficulty: Mixed (25% Foundational, 55% Application/Scenario, 20% Advanced/Hard)
Section 1: Bladder Disorders (Questions 1–30)
1. A 72-year-old patient with high-risk non-muscle invasive bladder cancer (NMIBC) receives BCG induction. After the
third instillation, he develops high fever (40°C), hypotension, and acute respiratory distress. What is the priority
intervention?
A) Intravesical lidocaine
B) IV ceftriaxone and discharge home
C) Anti-tuberculosis therapy (rifampin, isoniazid, ethambutol) plus corticosteroids
D) Repeat BCG at half dose
Correct Answer: C
Rationale: These are signs of BCG sepsis (disseminated infection). Immediate anti-TB therapy and steroids are life-
saving.
2. A 58-year-old woman with long-term ketamine use presents with severe suprapubic pain, hematuria, and
frequency. Cystoscopy shows a markedly contracted bladder (150 mL capacity) with diffuse inflammation. What is the
most effective long-term surgical option?
A) Augmentation cystoplasty
B) Sacral neuromodulation
C) Intravesical DMSO
D) Urethral dilation
Correct Answer: A
Rationale: Ketamine cystitis causes bladder fibrosis and contraction. Augmentation cystoplasty increases capacity
and reduces pain.
3. A patient with recurrent NMIBC on BCG maintenance develops granulomatous prostatitis on biopsy. He has no
systemic symptoms. What is the appropriate management?
A) Discontinue BCG permanently
B) Treat with 6 months of isoniazid
C) Continue BCG if asymptomatic
D) Perform radical prostatectomy
Correct Answer: C
Rationale: Asymptomatic granulomatous prostatitis is a known benign finding after BCG and not a contraindication
to continuing therapy.
,4. A 66-year-old man with interstitial cystitis has failed oral pentosan polysulfate, amitriptyline, and hydroxyzine. His
cystoscopy reveals a pinpoint bladder (250 mL capacity under anesthesia). What is the next best step?
A) Intravesical BCG
B) Hydrodistention alone
C) Cystectomy with urinary diversion
D) Sacral neuromodulation
Correct Answer: C
Rationale: End-stage IC/BPS with severely reduced capacity and refractory pain may require cystectomy.
Neuromodulation is not effective for end-stage.
5. A patient with orthotopic neobladder after radical cystectomy reports new-onset nocturnal incontinence only.
Urodynamics show a low-compliance neobladder (8 mL/cm H₂O) with no detrusor overactivity. What is the most likely
cause?
A) Sphincter weakness
B) Neobladder overactivity
C) Outlet obstruction
D) Metabolic acidosis
Correct Answer: B
Rationale: Low compliance indicates storage dysfunction; nocturnal incontinence often from neobladder
overactivity. Treat with anticholinergics.
6. A 48-year-old woman with recurrent UTIs (10 in past year) has negative cystoscopy and CT urogram. She is
postmenopausal not using estrogen. What is the most effective preventive therapy?
A) Daily cranberry extract
B) Vaginal estradiol cream
C) Methenamine hippurate
D) Post-coital cephalexin
Correct Answer: B
Rationale: Vaginal estrogen restores lactobacilli, lowers vaginal pH, and reduces UTI recurrence by 50-75%.
7. A patient with spinal cord injury (T6) on intermittent catheterization develops a bladder stone composed of calcium
phosphate. Urine culture is sterile. What is the most likely etiology?
A) Chronic alkaline urine from diet
B) Neurogenic bladder with incomplete emptying
C) Hypercalciuria of immobilization
D) Infection with urease-negative bacteria
Correct Answer: C
Rationale: Immobilization causes bone resorption and hypercalciuria, leading to calcium phosphate stones even
without infection.
8. A 62-year-old with BCG-unresponsive CIS refuses cystectomy. What intravesical agent has the highest response rate
as an alternative?
A) Gemcitabine plus docetaxel
B) Valrubicin
C) Mitomycin C
,D) Interferon-alpha
Correct Answer: A
Rationale: Sequential intravesical gemcitabine and docetaxel has a 2-year disease-free survival of 50-60% in BCG-
unresponsive NMIBC.
9. A patient with neurogenic detrusor overactivity due to multiple sclerosis is on oxybutynin IR 5 mg TID. She develops
severe dry mouth and constipation. What change would most reduce side effects while maintaining efficacy?
A) Switch to oxybutynin patch
B) Add pilocarpine
C) Reduce dose to BID
D) Switch to solifenacin 5 mg
Correct Answer: A
Rationale: Transdermal oxybutynin bypasses first-pass metabolism, reducing dry mouth and constipation
significantly.
10. A 70-year-old with high-grade T1 bladder cancer and CIS undergoes radical cystectomy. Pathology shows pT1N0,
negative margins, and lymphovascular invasion. What is the recommended adjuvant therapy?
A) Observation
B) Adjuvant chemotherapy (gemcitabine + cisplatin)
C) Adjuvant radiotherapy
D) Intravesical BCG via conduit
Correct Answer: B
Rationale: LVI in pT1N0 bladder cancer increases risk of occult metastases; adjuvant chemotherapy improves
survival.
11. A patient with chronic indwelling suprapubic catheter for 8 years develops squamous cell carcinoma of the
bladder. What is the most important risk factor?
A) Chronic inflammation and irritation
B) HPV infection
C) Tobacco use
D) Schistosoma haematobium
Correct Answer: A
Rationale: Chronic indwelling catheter causes squamous metaplasia → dysplasia → squamous cell carcinoma (rare
but well-described).
12. A 44-year-old woman with refractory OAB and PVR 25 mL fails mirabegron and solifenacin. She desires a non-daily
treatment. What third-line option has the lowest risk of permanent retention?
A) Botulinum toxin 100U
B) PTNS (12 weekly sessions)
C) Sacral neuromodulation
D) Percutaneous tibial nerve stimulation
Correct Answer: C
Rationale: Sacral neuromodulation does not cause urinary retention. Botulinum toxin causes transient retention in
15-20%.
13. A patient with interstitial cystitis and Hunner’s lesions undergoes fulguration. Post-op day 3, she reports severe
, pain radiating to the flank. What is the most likely complication?
A) Ureteral orifice injury with obstruction
B) Bladder perforation
C) Urinary tract infection
D) Pelvic hematoma
Correct Answer: A
Rationale: Fulguration near trigone can injure ureteral orifice, causing obstruction and flank pain. CT urogram
needed.
14. A patient on intravesical BCG develops a fever of 38.2°C, fatigue, and malaise 4 hours after instillation. What is the
appropriate next step?
A) Administer acetaminophen and observe
B) Start empiric antibiotics and anti-TB drugs
C) Remove the catheter immediately
D) Instill intravesical lidocaine
Correct Answer: A
Rationale: Low-grade fever (<38.5°C) within hours is common BCG reaction. Acetaminophen and observation. High
fever or hypotension = BCG sepsis.
15. A 75-year-old with Parkinson’s disease and OAB has a PVR of 350 mL and recurrent UTIs. Urodynamics show
detrusor underactivity. What is the safest OAB medication?
A) Oxybutynin
B) Mirabegron
C) Solifenacin
D) Trospium
Correct Answer: B
Rationale: Mirabegron does not worsen detrusor underactivity. Anticholinergics increase PVR and retention risk.
16. A patient with recurrent NMIBC receives BCG induction and then maintenance for 1 year. Surveillance cystoscopy
shows a 5 mm papillary tumor. TURBT reveals Ta low-grade. What is the next step?
A) Repeat BCG induction
B) Observation (no further BCG)
C) Cystectomy
D) Intravesical gemcitabine
Correct Answer: A
Rationale: Low-grade recurrence after BCG maintenance still responds to re-induction BCG.
17. A 62-year-old woman with mixed incontinence and severe prolapse (POP-Q stage 4) undergoes sacrocolpopexy
with concomitant mid-urethral sling. Post-op day 1, she is unable to void and PVR 600 mL. What is the most likely
cause?
A) Sling too tight
B) Post-operative urinary retention (normal)
C) Detrusor areflexia from anesthesia
D) Urethral edema
Correct Answer: B
