Urology Practice Questions

Q: A 44-year-old lady presents to the hospital with a ballotable flank mass. On CT imaging, the mass measures 4cm. Urine examination shows malignant cells. What is the most appropriate management for her condition?

Partial nephrectomy. ***Partial nephrectomy*** - For localized renal tumors measuring **≤ 4 cm (T1a)**, such as the one described, partial nephrectomy is the gold standard treatment, aiming to preserve renal function. - This approach, also known as **nephron-sparing surgery**, offers equivalent cancer control to radical nephrectomy for small tumors but with a lower risk of long-term **chronic kidney disease (CKD)** and associated cardiovascular morbidity. *Partial nephrectomy + neoadjuvant chemotherapy* - **Renal cell carcinoma (RCC)**, the most common type of kidney cancer, is notoriously resistant to conventional chemotherapy, so neoadjuvant chemotherapy is not a standard treatment for localized disease. - Neoadjuvant approaches for RCC, when used, typically involve **targeted therapy** or **immunotherapy** in the context of clinical trials for larger or more advanced tumors, not for a small 4cm mass. *Radical nephrectomy* - **Radical nephrectomy**, the removal of the entire kidney, is considered overtreatment for a small 4cm mass and is generally reserved for larger tumors (**>7 cm**) or when a partial nephrectomy is not technically feasible. - Performing a radical nephrectomy when a partial is possible unnecessarily sacrifices nephrons, increasing the patient's risk of developing **CKD** in the future. *Radical nephrectomy + postoperative radiotherapy* - RCC is largely **radioresistant**, and adjuvant radiotherapy after surgery has not been shown to improve survival or prevent recurrence for non-metastatic disease. - Radiotherapy is typically reserved for palliative care in cases of metastatic RCC, for example, to control symptoms from **bone** or **brain metastases**.

Q: How long should a couple use contraception post-vasectomy?

12-16 weeks. ***12-16 weeks***- Contraception is mandatory post-vasectomy until a follow-up semen analysis confirms **azoospermia** (complete absence of sperm).- The 12-16 week period accounts for the time needed for all existing sperm distal to the occlusion site to be ejaculated and cleared from the system.*4-6 weeks*- This time frame is generally too short to ensure complete clearance of all viable **sperm** stored in the **vas deferens** and related structures.- Relying on this duration significantly increases the risk of early **contraceptive failure** before azoospermia is achieved.*9-11 weeks*- While many men achieve clearance by the 9-week mark, the standard clinical protocol usually mandates waiting until **12 weeks** for the first definitive **semen analysis**.- Stopping contraception prematurely based on an estimated time frame, rather than laboratory confirmation, increases the hazard of unwanted pregnancy.*16-20 weeks*- Although safe, this duration unnecessarily exceeds the typical time required for the successful confirmation of **azoospermia**.- If the semen analysis at 12 weeks confirms **azoospermia**, contraception can typically cease immediately, making further delay unwarranted.

Q: What is incorrect about the image shown?

Microaerophilic hemolytic streptococci. ***Microaerophilic hemolytic streptococci*** - **For Fournier's gangrene**, the primary causative agents are typically a **polymicrobial infection (aerobic and anaerobic bacteria)**, not specifically microaerophilic hemolytic streptococci. - While streptococci can be involved, it is the synergistic action of multiple bacteria, especially gram-positive, gram-negative, and anaerobes, that characterizes the infection. *Gangrene of testis* - The image shows **Fournier's gangrene**, a severe form of necrotizing fasciitis affecting the perineum and genitals. - While the infection can spread and critically affect the scrotal tissues, the **testes themselves are often spared** due to their separate blood supply. *Seen in diabetics* - **Diabetics** are at significantly **increased risk** for developing Fournier's gangrene due to their impaired immune response and microvascular complications. - Approximately 30-60% of patients with Fournier's gangrene have underlying diabetes mellitus. *Obliterative arteritis* - **Obliterative endarteritis** is a key pathological feature of Fournier's gangrene, leading to **thrombosis of small vessels** and subsequent tissue necrosis and gangrene. - This vascular compromise is crucial in the rapid progression and tissue destruction seen in this condition.

Q: What is the clinical diagnosis?

Paraphimosis. ***Paraphimosis*** - The image shows the **glans penis** to be swollen and erythematous, with the **retracted foreskin** forming a tight constricting band behind it. - This condition occurs when the foreskin, once retracted, cannot be pulled back to its normal position, leading to **venous congestion** and edema of the glans. *Epispadias* - This is a congenital defect where the **urethral opening** is located on the **dorsal (upper) side** of the penis. - It would present as an abnormally placed urethral meatus, not foreskin entrapment. *Hypospadias* - This is a congenital condition where the **urethral opening** is located on the **ventral (underside)** of the penis. - The image does not show an abnormally placed urethral opening, but rather constriction of the glans by the foreskin. *Phimosis* - This condition involves the **inability to retract the foreskin** from the glans penis due to a tight opening. - The image depicts the foreskin *after* being retracted and then getting stuck, which is characteristic of paraphimosis, not phimosis.

Q: An 18-year-old patient presents with sudden agonizing pain in the groin and the lower abdomen. On physical examination, the testis seems high. The cremasteric reflex is lost. What is the most possible cause?

Testicular torsion. ***Testicular torsion*** - The sudden onset of **agonizing pain**, a **high-riding testis**, and a **lost cremasteric reflex** are classic signs of testicular torsion. - This condition is an acute surgical emergency that requires prompt intervention to preserve testicular viability. *Epididymo-orchitis* - Typically presents with a more **gradual onset of pain** and symptoms of inflammation, often associated with a urinary tract infection or sexually transmitted infection. - The cremasteric reflex would usually be present, and the testis would not typically be high-riding. *Mumps orchitis* - This condition is preceded by **parotitis (mumps)**, which is not mentioned in the patient's history. - While it causes testicular pain and swelling, it generally occurs several days after the onset of mumps and does not present with a high-riding testis or absent cremasteric reflex. *Idiopathic scrotal edema* - This is characterized by **swelling of the scrotal wall** without significant testicular pain upon palpation. - It usually presents with diffuse, non-pitting edema of the scrotum, with a preserved cremasteric reflex and normal testicular position.

Q: A 24-year-old male patient complains of painful and involuntary erection. Which of the following statement is false regarding this patient?

Relieved by ejaculation. ***Relieved by ejaculation*** - Priapism, especially **ischemic priapism**, is characterized by persistent erection **unrelated to sexual stimulation or desire** and is not relieved by ejaculation. Ejaculation does not resolve the underlying vascular issue causing the prolonged erection. - The pain associated with priapism often intensifies over time and is a key distinguishing feature from normal erections. *Due to defective venous drainage* - **Ischemic priapism**, the most common form, results from impaired venous outflow from the corpora cavernosa. This leads to **venous congestion** and trapping of deoxygenated blood. - This defective drainage causes **hypoxia and acidosis** within the cavernous tissue, contributing to pain and potential long-term damage. *Corpus spongiosum and glans penis are not involved* - In priapism, particularly ischemic priapism, the **corpora cavernosa** are primarily affected and become engorged. - The **corpus spongiosum** (which contains the urethra) and glans penis typically remain soft or less engorged because they have a separate venous drainage system which is not usually obstructed. *Intracavernosal injection of phenylephrine is used for low flow priapism* - **Phenylephrine** is an alpha-1 adrenergic agonist that causes **vasoconstriction** of the penile arterioles and venules leading to detumescence. - It is a common first-line treatment for **ischemic (low-flow) priapism**, helping to re-establish venous drainage and resolve the erection.

Q: A 65-year-old patient presents with sudden pain in the scrotum associated with prostration, pallor and pyrexia. What could be the most probable diagnosis?

Fournier's gangrene. **Fournier's gangrene** - **Fournier's gangrene** is a rapidly progressive, necrotizing fasciitis of the perineum and genital region, often presenting with sudden severe pain, prostration, pallor, and **fever (pyrexia)** in elderly patients. - The image likely shows extensive tissue necrosis and inflammation consistent with **Fournier's gangrene**, as the described symptoms and the patient's age (often associated with comorbidities like diabetes) increase suspicion for this life-threatening condition. *Torsion testis* - Testicular torsion typically presents with **acute, severe scrotal pain** and is more common in adolescents and young adults. - While it causes acute pain and possibly pallor from severe pain, it is less likely to cause widespread systemic symptoms like **pyrexia and prostration** in an elderly patient and does not involve the diffuse skin and subcutaneous tissue necrosis seen in the image. *Spermatocele* - A spermatocele is a **benign cyst** in the epididymis that usually presents as a painless mass. - It does not cause sudden pain, prostration, pallor, or pyrexia, nor does it involve tissue destruction. *Varicocele* - A varicocele is an **enlargement of veins within the scrotum** (pampiniform plexus), often described as feeling like a "bag of worms." - It typically causes a **dull ache** or heaviness, but not sudden severe pain, prostration, pallor, or pyrexia, and is not associated with the necrotic appearance.

Q: All are true about the conditions shown in the figure except?

Painless intermittent hematuria. ***Painless intermittent hematuria*** - While hematuria **can occur** with vesical calculus, the **classic teaching** emphasizes that **painless hematuria should raise suspicion for bladder malignancy** rather than benign calculus. - In bladder stones, hematuria is typically **associated with other symptoms** such as dysuria, frequency, suprapubic pain, and urgency, making it part of a **symptomatic complex** rather than an isolated painless finding. - The **key distinguishing feature** is that isolated, painless intermittent hematuria without other urinary symptoms is **more characteristic of bladder cancer** than vesical calculus. - Therefore, while hematuria occurs with bladder stones, **"painless intermittent hematuria" as an isolated finding** is NOT the typical presentation pattern. *Vesical calculus* - The image shows a large **radio-opaque shadow** in the bladder region, consistent with a **vesical calculus** (bladder stone). - Bladder stones result from urinary stasis, infection, bladder outlet obstruction (BPH), or foreign bodies. - Symptoms include dysuria, frequency, urgency, suprapubic pain, and hematuria. *Holmium laser* - **Holmium:YAG laser lithotripsy** is an effective endoscopic treatment for bladder stones. - The laser fragments stones into small pieces that can be irrigated out or extracted. - It has advantages of being minimally invasive with excellent stone-free rates. *Litholapaxy* - **Litholapaxy** is the standard endoscopic procedure for bladder stone removal. - Involves mechanical fragmentation using a **lithotrite** followed by evacuation of fragments. - Performed through a cystoscope under vision, making it safe and effective for most bladder stones.

Q: The following instrument is used for:

Bladder wash when urinary catheter gets blocked. ***Bladder wash when urinary catheter gets blocked*** - The image shows a **rubber bulb syringe**, also known as an **irrigation syringe** or **bulb syringe**. This instrument is commonly used to create suction or to instill fluid, making it ideal for procedures like bladder irrigation. - In cases where a **urinary catheter becomes blocked** by mucus plugs, clots, or debris, a bladder wash (irrigation) with sterile saline can help clear the obstruction and restore drainage. This syringe would enable a nurse or physician to manually flush the catheter. *Dilate urethral stricture* - **Urethral stricture dilation** requires specialized instruments such as **urethral dilators** or **balloon catheters**, which are designed to gradually widen the narrowed part of the urethra. - The flexible, bulb-type syringe shown is not rigid enough nor designed with the specific shape or size increments required for urethral dilation. *Relieve bladder outlet obstruction temporarily* - Temporary relief of **bladder outlet obstruction** (BOO) typically involves inserting a **urinary catheter** (e.g., Foley catheter) to drain urine directly from the bladder. - While a syringe can connect to a catheter for drainage, the syringe itself is not the primary instrument for relieving the obstruction; the catheter is. This syringe is for irrigation purposes, not direct catheterization to relieve obstruction. *Perform uroflowmetry* - **Uroflowmetry** is a diagnostic test that measures the **rate of urine flow** during voiding. It requires a specialized device called a **uroflowmeter**, which is typically a funnel or toilet-like apparatus connected to a sensor that measures flow rate and volume. - The pictured syringe plays no role in measuring the natural flow of urine during micturition.

Question 1

A 44-year-old lady presents to the hospital with a ballotable flank mass. On CT imaging, the mass measures 4cm. Urine examination shows malignant cells. What is the most appropriate management for her condition?

Accepted Answer

Partial nephrectomy

Answer

Partial nephrectomy + neoadjuvant chemotherapy

Answer

Radical nephrectomy + postoperative radiotherapy

Answer

Radical nephrectomy

Question 2

How long should a couple use contraception post-vasectomy?

Accepted Answer

12-16 weeks

Answer

4-6 weeks

Answer

9-11 weeks

Answer

16-20 weeks

Question 3

A 35-year-old patient presents with colicky pain and is diagnosed with a ureteric stone. Which of the following is the best diagnostic investigation in this case?

Accepted Answer

Non-contrast CT KUB

Answer

Ureteroscopy

Answer

Ultrasonography KUB

Answer

Contrast-enhanced CT KUB

Question 4

What is incorrect about the image shown?

Accepted Answer

Microaerophilic hemolytic streptococci

Answer

Gangrene of testis

Answer

Seen in diabetics

Answer

Obliterative endarteritis

Question 5

What is the clinical diagnosis?

Accepted Answer

Paraphimosis

Answer

Epispadias

Answer

Hypospadias

Answer

Phimosis

Question 6

An 18-year-old patient presents with sudden agonizing pain in the groin and the lower abdomen. On physical examination, the testis seems high. The cremasteric reflex is lost. What is the most possible cause?

Accepted Answer

Testicular torsion

Answer

Epididymo-orchitis

Answer

Mumps orchitis

Answer

Idiopathic scrotal edema

Question 7

A 24-year-old male patient complains of painful and involuntary erection. Which of the following statement is false regarding this patient?

Accepted Answer

Relieved by ejaculation

Answer

Due to defective venous drainage

Answer

Corpus spongiosum and glans penis are not involved

Answer

Intracavernosal injection of phenylephrine is used for low flow priapism

Question 8

A 65-year-old patient presents with sudden pain in the scrotum associated with prostration, pallor and pyrexia. What could be the most probable diagnosis?

Accepted Answer

Fournier's gangrene

Answer

Torsion testis

Answer

Spermatocele

Answer

Varicocele

Question 9

All are true about the conditions shown in the figure except?

Accepted Answer

Painless intermittent hematuria

Answer

Vesical calculus

Answer

Holmium laser

Answer

Litholapaxy

Question 10

The following instrument is used for:

Accepted Answer

Bladder wash when urinary catheter gets blocked

Answer

Dilate urethral stricture

Answer

Relieve bladder outlet obstruction temporarily

Answer

Perform uroflowmetry

Urology — MCQs

Urology — MCQs

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