Urology Practice Questions

Q: A patient operated for lower segment uterine fibroid had an uneventful surgery. Post operatively the urine output started to decrease, upto 20 ml/hr. Rapid IV fluid infusions were given with inj. Lasix and output increased to 70 ml/hr. Urine was clear. Patient complained of flank pain which was gradually progressing. Most common cause of such presentation would be:

Unilateral ureteral injury. ***Unilateral ureteral injury*** - A gradual decrease in urine output followed by an increase with fluid and diuretics, combined with **flank pain** after pelvic surgery, strongly suggests **unilateral ureteral obstruction** or injury, as the other kidney is still functioning. - The urine being clear indicates that the problem is not due to hemorrhage into the urinary tract but rather a mechanical blockage or injury affecting urine flow. *Haemorrhage* - Significant **hemorrhage** would typically cause signs of **hypovolemic shock** such as hypotension, tachycardia, and pallor, which are not mentioned. - While hemorrhage can decrease urine output, the subsequent increase with fluids and clear urine, along with flank pain, points away from bleeding as the primary cause of these specific symptoms. *Bladder injury* - A bladder injury would typically present with **hematuria** (blood in urine), inability to void, or leakage of urine into the peritoneal cavity, none of which are described. - While bladder injury can reduce urine output or cause discomfort, it wouldn't explain unilateral flank pain with clear urine in this context. *Acute renal failure* - **Acute renal failure** would typically cause a persistent and significant decrease in urine output despite fluid resuscitation and diuretics, and it would usually affect both kidneys. - The temporary improvement in urine output with fluids and the presence of unilateral flank pain make acute renal failure less likely as the initial cause compared to a localized surgical complication.

Q: Following a blunt trauma abdomen, a patient had renal laceration and urinoma. Even after 12 days, urinoma persisted, but the patient was stable and there was no fever. Next step in management would be:

Double-J stent. ***Double-J stent*** - A persistent urinoma for 12 days, even in a stable, afebrile patient, suggests ongoing urine leakage from the renal laceration. A **double-J stent** can bridge the laceration, **diverting urine flow** from the injury site into the bladder, which promotes healing and resolves the urinoma. - This minimally invasive procedure allows the kidney to drain properly, preventing further accumulation of urine and reducing the risk of complications such as infection or fibrosis without the need for open surgery. *Percutaneous nephrostomy* - While a percutaneous nephrostomy can drain urine, it usually involves external drainage and does not directly address the *internal* diversion of urine flow to promote healing of the laceration effectively. - This option is more commonly used for **obstructive uropathy** or in cases where the urinoma is infected and requires drainage which is not seen here as the patient is afebrile. *Wait and watch* - Waiting and watching for 12 days has already shown that the urinoma persists, indicating that the laceration is not healing spontaneously. - Continued persistence of a urinoma increases the risk of complications such as infection, obstruction, or fibrosis, so intervention is warranted. *Surgical exploration and repair* - **Surgical exploration and repair** is a more aggressive open surgical intervention, generally reserved for cases with ongoing hemorrhage, escalating infection, or significant tissue damage that cannot be managed by less invasive means. - Given the patient's stability and absence of fever, a less invasive approach like stenting is preferred before considering more extensive surgical repairs.

Q: A 60-year-old man with a history of nodular prostatic hyperplasia and recurrent cystitis presents with pain in the scrotum. His temperature is 38degC (101degF). Physical examination reveals a small, tender nodule attached to the testis. Which of the following is the most likely diagnosis?

Epididymitis. ***Epididymitis*** - The patient's history of **benign prostatic hyperplasia (BPH)** and **recurrent cystitis** increases the risk for ascending infections [2, 5], which are the most common cause of epididymitis in older men. - The presentation of **scrotal pain**, **fever**, and a **tender nodule attached to the testis** (most likely the epididymis) is classic for epididymitis [1, 2]. *Urethritis* - While urethritis can cause dysuria and urethral discharge, it typically does not present with a **tender scrotal nodule or fever** in this manner. - It could be a precursor to epididymitis [2], but the primary scrotal findings point elsewhere. *Orchitis* - **Orchitis** primarily involves inflammation of the **testis itself** and is often associated with mumps or viral infections. - While it can cause testicular pain and swelling, the description of a **small, tender nodule attached to the testis** is more indicative of epididymal involvement. *Spermatocele* - A **spermatocele** is a benign cyst that typically presents as a **painless, smooth mass** above the testis. - It does not cause acute pain, fever, or signs of inflammation.

Q: A 25-year-old male presents to emergency department following a road traffic accident. On examination there is a pelvic fracture and blood at urethral meatus. All of the following are true about this patient except:

Anterior urethra is the most likely site of injury. ***Anterior urethra is the most likely site of injury*** - In **pelvic trauma with urethral injury**, the **posterior urethra** (especially the membranous urethra) is the more commonly injured site due to its anatomical location within the pelvic ring. - Injuries to the anterior urethra are more typically associated with straddle injuries or direct perineal trauma, not pelvic fractures. *Retrograde urethrography should be done after the patient is stabilized* - **Retrograde urethrography (RGU)** is essential for diagnosing the site and extent of urethral injury and should be performed once the patient's hemodynamic status is stable. - Attempting RGU in an unstable patient could delay life-saving interventions for other injuries. *Rectal examination may reveal a large pelvic hematoma* - A **rectal examination** is crucial in major trauma, especially with pelvic fractures, as it can detect a high-riding prostate, pelvic hematoma, or rectal lacerations. - A **large pelvic hematoma** can be palpated as a fluctuant mass during a rectal exam, indicating significant pelvic bleeding. *Foley catheter may be carefully passed if the RGU is normal* - If the **retrograde urethrography (RGU)** shows no extravasation and a normal urethral lumen, it confirms the integrity of the urethra, allowing for careful placement of a **Foley catheter**. - A Foley catheter should *not* be inserted blindly if urethral injury is suspected, as this can worsen the injury and convert a partial tear into a complete one.

Q: A young man gets into a fight after taking beer and is kicked in the lower abdomen. There was pelvic fracture, blood at meatus. Most likely cause is

Rupture of membranous urethra. ***Rupture of membranous urethra*** - A **pelvic fracture** in a male, especially with a kick to the lower abdomen, is highly suspicious for injury to the **membranous urethra**, which is fixed and less mobile than the bulbar urethra and is often injured with shearing forces from pelvic trauma. - **Blood at the meatus** is a classic sign of urethral injury, distinguishing it from a bladder rupture alone. *Bulbar urethral injury* - This typically occurs with a **straddle injury** or a direct blow to the perineum, which is less consistent with a lower abdominal kick and pelvic fracture. - While blood at the meatus can occur, the presence of a pelvic fracture points more specifically to membranous urethral injury. *Bladder rupture* - While a **bladder rupture** can result from significant lower abdominal trauma and pelvic fractures, **blood at the meatus** is less common unless there's a co-existing urethral injury. - Patients with bladder rupture often present with gross hematuria, suprapubic pain, and inability to void, and less frequently with blood specifically at the meatus. *Kidney laceration* - A **kidney laceration** typically presents with **flank pain**, hematuria (often macroscopic), and possibly signs of shock, and is usually associated with significant trauma to the flank or back. - It is less likely to cause isolated blood at the meatus without other prominent renal injury signs, and a lower abdominal kick and pelvic fracture are less directly implicated in kidney injury.

Q: BCG is used for the treatment of:

Treatment of superficial bladder cancer. ***Treatment of superficial bladder cancer*** - **BCG (Bacille Calmette-Guérin)** is a live attenuated strain of *Mycobacterium bovis* that is effective as an **immunotherapy** for superficial bladder cancer. - It is instilled directly into the bladder, triggering a localized immune response that targets and destroys cancer cells, preventing recurrence and progression. *Treatment of tuberculosis* - While BCG is derived from *Mycobacterium bovis*, it is primarily used as a **vaccine** to prevent severe forms of tuberculosis, especially in children, rather than a treatment for active disease. - Active tuberculosis is typically treated with a multi-drug regimen of **antibiotics**, not BCG. *Treatment of anthrax* - Anthrax is caused by **Bacillus anthracis** and is treated with specific **antibiotics** such as ciprofloxacin or doxycycline. - **BCG has no role** in the treatment of anthrax. *All of the options* - As BCG is not used for the treatment of tuberculosis or anthrax, this option is incorrect. - Its established therapeutic use is primarily in the management of superficial bladder cancer.

Q: A 70 year old patient with benign prostatic hyperplasia underwent transurethral resection of prostate under spinal anaesthesia. One hour later, he developed vomiting and altered sensorium. Which of the following is the most probable cause?

Water intoxication (TURP syndrome). ***Water intoxication (TURP syndrome)*** - **Transurethral resection of the prostate (TURP)** uses a hypotonic irrigation solution, which can be absorbed through venous sinuses opened during resection. - This absorption leads to **dilutional hyponatremia** and **fluid overload**, causing symptoms such as vomiting, altered sensorium, and even seizures or coma, collectively known as **TURP syndrome**. *Hyperkalemia* - **Hyperkalemia** is not a common complication of TURP. While irrigation solutions can cause electrolyte imbalances, they usually lead to dilutional hyponatremia, not elevated potassium. - Symptoms of hyperkalemia typically include **cardiac arrhythmias** and muscle weakness, not primarily vomiting and altered sensorium in this rapid onset. *Over dosage of spinal anaesthetic agent* - An overdose of spinal anesthetic agent would likely manifest earlier during or immediately after the spinal injection, with symptoms like **hypotension**, **bradycardia**, or **respiratory depression**. - **Altered sensorium** and vomiting occurring one hour post-procedure with intact initial recovery from anesthesia are less typical for acute spinal overdose. *Rupture of bladder* - A **bladder rupture** during TURP would typically present with acute lower abdominal pain, abdominal distension, and signs of **peritonitis**, or oliguria/anuria. - While it can cause systemic effects, vomiting and altered sensorium as the primary symptoms one hour later are not the most characteristic presentation for bladder perforation.

Q: Management of RCC less than 4 cm in size:

Partial nephrectomy. ***Correct: Partial nephrectomy*** - For **renal cell carcinoma (RCC) less than 4 cm (T1a)**, partial nephrectomy is the **gold standard** as it offers equivalent oncological outcomes to radical nephrectomy while preserving renal function. - This approach minimizes the risk of **chronic kidney disease** and its associated complications without compromising cancer control for appropriately selected smaller tumors. - **Nephron-sparing surgery** is now the preferred approach per EAU and AUA guidelines for small renal masses. *Incorrect: Surgery followed by chemotherapy* - While surgery is the primary treatment, **adjuvant chemotherapy** is generally **not effective** for localized RCC and is not routinely recommended for small tumors. - Systemic therapies are typically reserved for **advanced or metastatic RCC**, or in specific clinical trials. *Incorrect: Radical nephrectomy* - This involves removing the entire kidney, which is typically reserved for **larger tumors (T1b and above)**, centrally located tumors, or those with significant renal parenchymal involvement. - For tumors under 4 cm, radical nephrectomy leads to **unnecessary loss of renal function** compared to partial nephrectomy. *Incorrect: Chemotherapy* - **RCC is notoriously chemoresistant**, meaning traditional chemotherapy drugs have very limited efficacy in treating this cancer. - Chemotherapy alone is **not a primary treatment modality** for localized RCC due to its poor response rates in this cancer type.

Q: A man is brought to the emergency after he fell into a man hole and injured his perineum. He feels the urge to micturate but is unable to pass urine and there is blood at the tip of the meatus with extensive swelling of the penis and scrotum. What is the location of the injury?

Bulbar urethra. ***Bulbar urethra*** - Injury to the **bulbar (spongy) urethra** in the perineum, often from a straddle injury or fall into a manhole, typically causes the extravasation of urine and blood into the **superficial perineal pouch**. - This leads to **extensive swelling of the penis and scrotum** (butterfly hematoma) because the superficial perineal fascia (Colles' fascia) is continuous with dartos fascia of the penis and scrotum, preventing blood from extending into the thighs or abdominal wall, combined with an inability to micturate with blood at the meatus. *Membranous urethra* - Injury to the **membranous urethra** is usually associated with **pelvic fractures** and tends to cause extravasation into the **deep perineal space** and then the retroperitoneum, leading to swelling in the lower abdomen or around the anus, not primarily the penis and scrotum. - While it can cause inability to micturate and blood at the meatus, the characteristic extensive swelling of the penis and scrotum points away from this location. *Prostatic urethra* - Injuries to the **prostatic urethra** are rare and typically occur with **severe pelvic crush injuries** given its protected position deep within the pelvis. - While it would cause inability to urinate, the nature of the fall and the distribution of swelling (predominantly penis and scrotum) are not typical for prostatic urethral injury. *Bladder* - A bladder injury from a fall would likely present with suprapubic pain and hematuria, but the inability to urinate combined with **blood at the meatus** and extensive swelling limited to the penis and scrotum is not characteristic of isolated bladder trauma. - **Blood at the meatus** is a classic sign of urethral, not typically bladder, injury.

Question 1

A patient operated for lower segment uterine fibroid had an uneventful surgery. Post operatively the urine output started to decrease, upto 20 ml/hr. Rapid IV fluid infusions were given with inj. Lasix and output increased to 70 ml/hr. Urine was clear. Patient complained of flank pain which was gradually progressing. Most common cause of such presentation would be:

Accepted Answer

Unilateral ureteral injury

Answer

Haemorrhage

Answer

Bladder injury

Answer

Acute renal failure

Question 2

Following a blunt trauma abdomen, a patient had renal laceration and urinoma. Even after 12 days, urinoma persisted, but the patient was stable and there was no fever. Next step in management would be:

Accepted Answer

Double-J stent

Answer

Percutaneous nephrostomy

Answer

Wait and watch

Answer

Surgical exploration and repair

Question 3

A 60-year-old man with a history of nodular prostatic hyperplasia and recurrent cystitis presents with pain in the scrotum. His temperature is 38degC (101degF). Physical examination reveals a small, tender nodule attached to the testis. Which of the following is the most likely diagnosis?

Accepted Answer

Epididymitis

Answer

Urethritis

Answer

Orchitis

Answer

Spermatocele

Question 4

A 25-year-old male presents to emergency department following a road traffic accident. On examination there is a pelvic fracture and blood at urethral meatus. All of the following are true about this patient except:

Accepted Answer

Anterior urethra is the most likely site of injury

Answer

Retrograde urethrography should be done after the patient is stabilized

Answer

Rectal examination may reveal a large pelvic hematoma

Answer

Foley catheter may be carefully passed if the RGU is normal

Question 5

A young man gets into a fight after taking beer and is kicked in the lower abdomen. There was pelvic fracture, blood at meatus. Most likely cause is

Accepted Answer

Rupture of membranous urethra

Answer

Bulbar urethral injury

Answer

Bladder rupture

Answer

Kidney laceration

Question 6

BCG is used for the treatment of:

Accepted Answer

Treatment of superficial bladder cancer

Answer

Treatment of tuberculosis

Answer

Treatment of anthrax

Answer

All of the options

Question 7

A 70 year old patient with benign prostatic hyperplasia underwent transurethral resection of prostate under spinal anaesthesia. One hour later, he developed vomiting and altered sensorium. Which of the following is the most probable cause?

Accepted Answer

Water intoxication (TURP syndrome)

Answer

Hyperkalemia

Answer

Overdose of spinal anaesthetic agent

Answer

Rupture of bladder

Question 8

Management of RCC less than 4 cm in size:

Accepted Answer

Partial nephrectomy

Answer

Surgery followed by chemotherapy

Answer

Radical nephrectomy

Answer

Chemotherapy

Question 9

A man is brought to the emergency after he fell into a man hole and injured his perineum. He feels the urge to micturate but is unable to pass urine and there is blood at the tip of the meatus with extensive swelling of the penis and scrotum. What is the location of the injury?

Accepted Answer

Bulbar urethra

Answer

Membranous urethra

Answer

Prostatic urethra

Answer

Bladder

Question 10

A 10-year-old boy came to emergency with complaints of severe pain in right scrotum that is not relieved for the past 1 hour. On examination, testicular torsion of the right side is suspected. The surgical intervention should be:

Accepted Answer

Immediate exploration of the affected side and operate opposite side even if asymptomatic

Answer

Delayed exploration on the affected side along with the opposite side even if asymptomatic

Answer

Immediate scrotal exploration of the affected side and operate opposite side if symptomatic

Answer

Delay exploration and operate opposite side if symptomatic

Urology — MCQs

Urology — MCQs

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