Urology Practice Questions

Q: A 60-year-old male undergoes TURP. After 3 days, the patient develops altered consciousness and drowsiness. What is the most probable diagnosis?

Hyponatremia. **Explanation:** The patient is presenting with **TURP Syndrome**, a classic complication occurring due to the systemic absorption of large volumes of non-conductive irrigation fluid (traditionally 1.5% Glycine) through opened prostatic venous sinuses during Transurethral Resection of the Prostate. **1. Why Hyponatremia is Correct:** The absorption of hypotonic irrigation fluid leads to **dilutional hyponatremia** and hypervolemia. As serum sodium levels drop (typically below 120 mEq/L), cerebral edema develops. This manifests clinically as altered consciousness, drowsiness, confusion, seizures, and in severe cases, coma. Glycine itself can also act as an inhibitory neurotransmitter, contributing to visual disturbances and encephalopathy. **2. Why Other Options are Incorrect:** * **Hypernatremia:** TURP involves the absorption of water/hypotonic fluids, which decreases sodium concentration; it never causes an increase in sodium. * **Stroke:** While possible in elderly patients, the temporal relationship with a TURP procedure and the specific metabolic risk makes TURP syndrome significantly more probable. * **Meningitis:** While spinal anesthesia can cause "Post-Dural Puncture Headache," acute altered sensorium after 3 days without fever or nuchal rigidity makes meningitis highly unlikely. **High-Yield Clinical Pearls for NEET-PG:** * **Prevention:** Limit resection time to **<60 minutes**, keep irrigation bag height **<60 cm**, and use Bipolar TURP (which allows the use of Normal Saline, eliminating the risk of hyponatremia). * **Treatment:** Mild cases require fluid restriction and diuretics (Furosemide). Severe symptomatic hyponatremia requires **3% Hypertonic Saline** (corrected slowly to avoid Central Pontine Myelinolysis). * **Early Sign:** If the patient is under spinal anesthesia, the earliest sign is often **bradycardia and hypertension** (due to fluid overload) or sudden apprehension/confusion.

Q: Which condition is characterized by an improvement in urine stream after its initial onset?

Urethral stricture. **Explanation:** In **Urethral Stricture**, the narrowing of the urethral lumen creates high resistance to urine flow. At the start of micturition, the stream is weak or thin. However, as the bladder contracts more vigorously to overcome the obstruction, the high proximal pressure causes the strictured segment to dilate slightly. This physiological expansion leads to a paradoxical **improvement in the urine stream** after the initial onset. **Analysis of Options:** * **Prostate Enlargement (BPH):** Characterized by hesitancy, a weak stream that remains weak or worsens towards the end (terminal dribbling), and a feeling of incomplete emptying. The stream does not improve during the act. * **Marion’s Disease (Bladder Neck Obstruction):** This involves congenital hypertrophy of the internal sphincter. It typically presents with a consistently poor stream and difficulty initiating voiding, similar to BPH but in younger patients. * **Posterior Urethral Valves (PUV):** This is the most common cause of bladder outlet obstruction in male infants. It is characterized by a weak, dribbling stream from birth, often associated with a palpable bladder and bilateral hydronephrosis. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Retrograde Urethrogram (RGU) is the investigation of choice to define the site and length of the stricture. * **Most Common Site:** The bulbar urethra is the most common site for post-inflammatory and idiopathic strictures. * **Management:** Short strictures (<2cm) are managed by **Direct Vision Internal Urethrotomy (DVIU)** or dilatation; long strictures require **Urethroplasty** (e.g., BMG - Buccal Mucosa Graft).

Q: Which one of the following does not indicate a good prognosis in carcinoma of the penis?

Tumor size less than 2 cm. In Penile Carcinoma, the prognosis is primarily determined by the **pathological stage (TNM)** and the **histological grade**, rather than the absolute physical size of the primary tumor. ### **Why Option A is the Correct Answer** **Tumor size (< 2 cm)** is not a reliable prognostic indicator in penile cancer. A small tumor (e.g., 1.5 cm) that is high-grade (undifferentiated) or has invaded the corpus cavernosum (T2) or corpus spongiosum carries a much worse prognosis than a large, 4 cm superficial verrucous carcinoma. In the current AJCC TNM staging, "size" is not a criteria; instead, the **depth of invasion** and **nodal status** are the critical determinants of survival. ### **Explanation of Incorrect Options** * **B. No regional lymph node metastasis:** This is the **most important** prognostic factor. The presence and extent of inguinal lymph node involvement directly correlate with 5-year survival rates. Absence of nodal spread indicates an excellent prognosis. * **C. No invasion of subepithelial connective tissue:** This refers to **Stage Ta/Tis**. Tumors confined to the epithelium without invading the subepithelial connective tissue (lamina propria) have a negligible risk of metastasis and an excellent prognosis. * **D. No distant metastases:** Distant metastasis (M1) in penile cancer is rare but fatal. Its absence is a prerequisite for a favorable long-term outcome. ### **Clinical Pearls for NEET-PG** * **Most common histological type:** Squamous Cell Carcinoma (95%). * **Most important prognostic factor:** Status of inguinal lymph nodes. * **Sentinel Lymph Node:** The "Sentinel node of Cabanas" is located near the superficial epigastric vein. * **Staging Insight:** T1 is divided into **T1a** (no lymphovascular invasion, well-differentiated) and **T1b** (lymphovascular invasion or high grade). T1b has a significantly higher risk of nodal micrometastasis.

Q: Which of the following refinements of serum PSA is used to determine the need for TRUS guided biopsy of the prostate, even when the level of serum PSA is still in the normal range?

PSA velocity. **Explanation:** **PSA Velocity (PSAV)** refers to the rate of change in serum PSA levels over time. It is the most sensitive refinement for detecting prostate cancer in men whose absolute PSA levels are still within the "normal" range (typically 0.75 ng/mL per year**—is highly suggestive of malignancy and serves as an indication for a TRUS-guided biopsy, even if the total PSA value has not yet crossed the standard threshold. **Analysis of Incorrect Options:** * **PSA Density (PSAD):** This is the ratio of serum PSA to the volume of the prostate (measured by TRUS). It is primarily used to differentiate BPH from cancer in patients with "borderline" PSA levels (4–10 ng/mL). A value >0.15 is considered suspicious. * **Free/Total PSA Ratio:** Since prostate cancer produces more "bound" PSA, a lower percentage of free PSA (<15–20%) indicates a higher risk of cancer. Like PSAD, it is most useful in the 4–10 ng/mL "gray zone." * **Complexed/Total PSA Ratio:** Most PSA in the blood is complexed with alpha-1-antichymotrypsin. While useful, it does not supersede PSAV in identifying risk within the normal range. **High-Yield Clinical Pearls for NEET-PG:** * **Normal PSA:** <4 ng/mL. * **PSA Velocity Requirement:** To be accurate, at least 3 serial PSA measurements should be taken over a period of 18–24 months. * **Age-Specific PSA:** PSA levels naturally rise with age due to prostate volume increase (e.g., <2.5 for age 40–49; <6.5 for age 70–79). * **Most common site for Prostate Cancer:** Peripheral zone (70%). * **Standard Biopsy:** 12-core systematic TRUS-guided biopsy.

Q: All of the following are true about vasectomy, EXCEPT:

Sperm granulomas are less common if electrocautery is used.. **Explanation:** The correct answer is **B**. This statement is false because **electrocautery actually increases the risk of sperm granulomas**. A sperm granuloma is an inflammatory response to leaking sperm. When electrocautery is used to seal the vas deferens, it can cause thermal damage and necrosis of the tissue, which may lead to a higher incidence of "blowouts" or leakage from the proximal stump compared to simple ligation or mucosal cautery techniques. **Analysis of other options:** * **Option A:** It takes approximately **3 months (or 20 ejaculations)** to achieve azoospermia. Patients must use alternative contraception until two consecutive semen analyses confirm the absence of sperm. * **Option C:** Vasectomy reversal (Vasovasostomy) success is time-dependent. Success rates are highest (up to 90%) if performed within **10 years**; after this period, secondary changes in the epididymis and the development of anti-sperm antibodies reduce the chances of pregnancy. * **Option D:** **Post-vasectomy pain syndrome (PVPS)** is a recognized complication, characterized by chronic testicular pain lasting >3 months, affecting about 1-2% of patients. **High-Yield Clinical Pearls for NEET-PG:** * **Most common complication:** Hematoma or infection. * **Most common late complication:** Sperm granuloma (most frequent at the site of the proximal stump). * **No-Scalpel Vasectomy (NSV):** Associated with fewer infections and hematomas compared to the traditional incisional method. * **Failure Rate:** Approximately 0.1% (1 in 1000), usually due to recanalization.

Q: A patient presents with pain and tenderness in the left iliac fossa. Ultrasonography shows a 3 cm stone in the renal pelvis without any hydronephrosis. What is the most appropriate management?

Percutaneous Nephrolithotomy (PCNL). ### Explanation The patient presents with a **3 cm stone in the renal pelvis**. According to the current EAU (European Association of Urology) guidelines, the size of the stone is the primary determinant for the choice of intervention. **1. Why PCNL is the Correct Answer:** * **Stone Size:** For renal stones **>20 mm (2 cm)**, Percutaneous Nephrolithotomy (PCNL) is the gold standard and first-line treatment. It offers the highest stone-free rate (SFR) in a single setting for large calculi. * **Location:** A 3 cm stone in the renal pelvis is too large for effective fragmentation by ESWL and would likely result in "Steinstrasse" (stone street) or incomplete clearance. **2. Why Other Options are Incorrect:** * **ESWL (Option B):** This is generally preferred for stones **<20 mm**. For stones larger than 2 cm, the success rate drops significantly, and the risk of ureteral obstruction from fragmented debris increases. * **Diuretics (Option C):** Diuretics have no role in the active management or dissolution of a 3 cm pelvic stone. * **Medical Dissolution Therapy (Option D):** Potassium citrate is used for **Uric Acid stones**. However, even for uric acid stones, a 3 cm stone usually requires surgical debulking or intervention due to the time required for dissolution and the risk of symptoms. **Clinical Pearls for NEET-PG:** * **First-line for 10 mm often favor PCNL/RIRS). * **First-line for >20 mm stone:** PCNL. * **Staghorn Calculi:** PCNL is the treatment of choice. * **Steinstrasse:** A complication of ESWL where fragmented stone pieces obstruct the ureter.

Q: A 60-year-old male smoker presents with one day of painless gross hematuria. Intravenous urography (IVU) shows a 1.2 cm filling defect at the lower pole of the infundibulum. What is the next best investigation to be done?

Cystoscopy. ### Explanation **1. Why Cystoscopy is the Correct Answer:** The clinical presentation of **painless gross hematuria** in an elderly male smoker is **bladder cancer** until proven otherwise. While the IVU shows a filling defect in the upper tract (infundibulum), bladder tumors are significantly more common than upper tract urothelial carcinomas (UTUC). Furthermore, urothelial tumors are often **multifocal** (field change theory). In any patient over 40 with unexplained gross hematuria, **Cystoscopy** is the gold standard and mandatory initial investigation to rule out synchronous bladder lesions, which occur in approximately 10–15% of patients with upper tract tumors. It allows for direct visualization and biopsy. **2. Why Other Options are Incorrect:** * **Urine Cytology (B):** While useful for detecting high-grade malignant cells, it has low sensitivity for low-grade tumors and cannot localize the lesion. It is an adjunct, not the definitive next step. * **Ultrasound Abdomen (C):** Ultrasound is a good screening tool but lacks the sensitivity of IVU or CT Urography for small infundibular filling defects (1.2 cm) and cannot reliably rule out small bladder tumors. * **DMSA Scan (D):** This is a functional renal scan used to assess cortical scarring (e.g., in pediatric reflux or pyelonephritis). It has no role in the evaluation of hematuria or suspected malignancy. **3. Clinical Pearls for NEET-PG:** * **Rule of Thumb:** Painless gross hematuria in an elderly smoker = **Cystoscopy + CT Urography.** * **Filling Defect on IVU (Differential Diagnosis):** "Radiolucent" stones (Uric acid), Urothelial Carcinoma, Blood clot, or Sloughed papilla. * **Field Change Theory:** The entire urothelium (from renal pelvis to urethra) is at risk; hence, if you find a tumor in one location, you must check the others. * **Most common site for UTUC:** Renal pelvis, followed by the ureter.

Q: Which paraneoplastic syndrome is NOT typically seen in renal cell carcinoma?

Acanthosis nigricans. Renal Cell Carcinoma (RCC) is famously known as the **"Internist’s Tumor"** because it can present with a wide array of paraneoplastic syndromes (PNS) due to the ectopic secretion of various hormones and cytokines. **Why Acanthosis Nigricans is the Correct Answer:** Acanthosis nigricans (velvety hyperpigmentation in skin folds) is a cutaneous marker of internal malignancy, but it is most strongly associated with **gastric adenocarcinoma** and other GI malignancies. It is **not** a typical feature of RCC. **Explanation of Incorrect Options (Common PNS in RCC):** * **Polycythemia (Option C):** This is a classic PNS in RCC caused by the ectopic production of **Erythropoietin (EPO)**. It occurs in about 1-5% of patients. * **Hypercalcemia (Option D):** This is the most common metabolic PNS in RCC. It is usually caused by the secretion of **Parathyroid Hormone-related Protein (PTHrP)**, mimicking primary hyperparathyroidism. * **Amyloidosis (Option B):** Chronic inflammation associated with RCC can lead to **Secondary (AA) Amyloidosis**, which may present as nephrotic syndrome in the contralateral kidney. **High-Yield Clinical Pearls for NEET-PG:** * **Stauffer’s Syndrome:** Reversible hepatic dysfunction (elevated LFTs) in the absence of liver metastases; a unique PNS of RCC. * **Hypertension:** Often caused by increased **Renin** production. * **Cushing’s Syndrome:** Rarely occurs due to ectopic **ACTH** production. * **Classic Triad:** Hematuria, flank pain, and palpable mass (seen in only 10% of cases, usually indicates advanced disease).

Question 1

A 60-year-old male undergoes TURP. After 3 days, the patient develops altered consciousness and drowsiness. What is the most probable diagnosis?

Accepted Answer

Hyponatremia

Answer

Hypernatremia

Answer

Stroke

Answer

Meningitis due to spinal anesthesia

Question 2

Which condition is characterized by an improvement in urine stream after its initial onset?

Accepted Answer

Urethral stricture

Answer

Prostate enlargement

Answer

Marion's disease

Answer

Posterior urethral valves

Question 3

Which one of the following does not indicate a good prognosis in carcinoma of the penis?

Accepted Answer

Tumor size less than 2 cm

Answer

No regional lymph node metastasis

Answer

No invasion of subepithelial connective tissue

Answer

No distant metastases

Question 4

Which of the following refinements of serum PSA is used to determine the need for TRUS guided biopsy of the prostate, even when the level of serum PSA is still in the normal range?

Accepted Answer

PSA velocity

Answer

Prostate-specific antigen density (PSAD)

Answer

Free/Total PSA ratio

Answer

Complexed/Total PSA ratio

Question 5

All of the following are true about vasectomy, EXCEPT:

Accepted Answer

Sperm granulomas are less common if electrocautery is used.

Answer

It takes about 3 months before the sperm stores are used up.

Answer

Reversal is most successful within 10 years of the initial surgery.

Answer

There is a risk of chronic testicular pain.

Question 6

A patient presents with pain and tenderness in the left iliac fossa. Ultrasonography shows a 3 cm stone in the renal pelvis without any hydronephrosis. What is the most appropriate management?

Accepted Answer

Percutaneous Nephrolithotomy (PCNL)

Answer

Extracorporeal Shock Wave Lithotripsy (ESWL)

Answer

Diuretics

Answer

Medical dissolution therapy with potassium citrate

Question 7

A 60-year-old male smoker presents with one day of painless gross hematuria. Intravenous urography (IVU) shows a 1.2 cm filling defect at the lower pole of the infundibulum. What is the next best investigation to be done?

Accepted Answer

Cystoscopy

Answer

Urine cytology

Answer

Ultrasound abdomen

Answer

DMSA scan

Question 8

Which paraneoplastic syndrome is NOT typically seen in renal cell carcinoma?

Accepted Answer

Acanthosis nigricans

Answer

Amyloidosis

Answer

Polycythemia

Answer

Hypercalcemia

Question 9

What does strangury mean?

Accepted Answer

Extreme wretching sensation at the end of micturition causing distress

Answer

Painless terminal hematuria

Answer

Painful hematuria

Answer

Pain during micturition

Question 10

A 34-year-old male undergoes vasectomy. Which of the following is the most frequent immediate complication of this procedure?

Accepted Answer

Hematoma

Answer

Infection

Answer

Impotence

Answer

Spontaneous reanastomosis

Urology — MCQs

Urology — MCQs

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