Hydronephrosis — MCQs

10 questions

Which of the following is typically seen on ultrasound in acute pyelonephritis?

A 22-year-old primigravida visits ANC OPD with 20 weeks POG. On examination uterine height reveals a 16-week size. USG shows reduced liquor. What will be the diagnosis?

Posterior urethral valve is diagnosed on micturating cystourethrogram by-

Most common cause of urinary obstruction in a male infant is -

Unilateral renal agenesis is associated with:

Reflux into grossly dilated ureter belongs to which grade of Vesicoureteric Reflux?

A one-year-old male child presented with a poor urinary stream since birth. The initial investigation of choice for evaluation is:

A three-year-old boy presents with a poor urinary stream. Most likely cause is -

A neonate presenting with ascites is diagnosed with urinary ascites. What is the most common cause?

Q10

A 1-month-old baby brought by the mother complaining of a mass on back associated with wetness and inability of both legs to move ever since birth. Possible diagnosis: (Recent NEET Pattern 2016-17)

Hydronephrosis Indian Medical PG Practice Questions and MCQs

Question 1: Which of the following is typically seen on ultrasound in acute pyelonephritis?

A. Decreased vascularity
B. Enlarged kidney with diffuse swelling (Correct Answer)
C. Localized hypoechogenic areas in the kidney
D. Fluid collection around the kidney

Explanation: ***Enlarged kidney with diffuse swelling*** - In **acute pyelonephritis**, the **most consistent ultrasound finding** is **renal enlargement** with **diffuse swelling** of the affected kidney. - This occurs due to **inflammatory edema** and increased fluid content within the renal parenchyma, representing the body's inflammatory response to infection. - **Diffuse enlargement** is present in the majority of cases and is often the **earliest sonographic manifestation**, making it the most typical finding. *Localized hypoechogenic areas in the kidney* - **Focal or multifocal hypoechoic areas** are indeed **highly characteristic** of acute pyelonephritis and represent zones of **parenchymal edema and inflammation**. - These are seen in approximately **20-80% of cases** and are considered a hallmark feature. - However, they may not be present in all cases, particularly in early or mild disease, whereas **renal enlargement is more consistently present**. - When visible, these areas have high specificity for the diagnosis. *Fluid collection around the kidney* - **Perinephric fluid collections** or abscesses indicate **complicated pyelonephritis** with extension of infection beyond the renal capsule. - These are **not typical findings in uncomplicated acute pyelonephritis** and suggest more severe or advanced infection requiring aggressive management. *Decreased vascularity* - Acute pyelonephritis typically shows **increased vascularity** on color Doppler due to **hyperemia and inflammatory vasodilation**. - **Decreased vascularity** is associated with **renal infarction**, severe ischemia, or chronic scarring—not acute bacterial infection.

Question 2: A 22-year-old primigravida visits ANC OPD with 20 weeks POG. On examination uterine height reveals a 16-week size. USG shows reduced liquor. What will be the diagnosis?

A. Bilateral renal agenesis (Correct Answer)
B. Bartter’s syndrome
C. Liddle syndrome
D. Fetal anemia

Explanation: ***Renal agenesis*** - **Bilateral renal agenesis** leads to **oligohydramnios** because the fetal kidneys are the primary producers of amniotic fluid after 16 weeks of gestation. - The reduced amniotic fluid (liquor) is consistent with the decreased uterine size (16-week size at 20 weeks POG) and is a hallmark of this condition, often resulting in **Potter sequence**. *Bartter’s syndrome* - This is a rare, inherited renal tubulopathy characterized by significant electrolyte disturbances (hypokalemia, metabolic alkalosis, hypercalciuria) due to impaired ion transport. - While it affects kidney function, it does not typically cause severe **oligohydramnios** or **renal agenesis** and would not explain the small uterine size in this scenario. *Liddle syndrome* - This is a rare genetic disorder characterized by early-onset hypertension, hypokalemia, and metabolic alkalosis, due to constitutive activation of the epithelial sodium channel (ENaC) in the collecting ducts. - It does not involve structural kidney abnormalities or significantly impact amniotic fluid volume during pregnancy to cause the described findings. *Fetal anemia* - Fetal anemia can lead to complications such as **hydrops fetalis**, which would typically cause **polyhydramnios** or a uterine size larger than expected due to fluid accumulation, not oligohydramnios or a smaller uterine size. - Reduced liquor and a small uterine size are not characteristic presentations of fetal anemia.

Question 3: Posterior urethral valve is diagnosed on micturating cystourethrogram by-

A. Dilatation of posterior urethra (Correct Answer)
B. Bladder wall hypertrophy
C. Bladder neck contracture
D. Vesico-Ureteric reflux

Explanation: ***Dilatation of posterior urethra*** - **Posterior urethral valves (PUV)** create an obstruction in the **posterior urethra**, leading to its characteristic dilatation during micturition due to increased pressure. - This **dilatation** is a direct radiographic sign of the anatomical obstruction caused by the valves. *Bladder wall hypertrophy* - **Bladder wall hypertrophy** is a secondary change that occurs over time due to the bladder working harder against the obstruction caused by PUV, but it is not the primary diagnostic feature on a micturating cystourethrogram (MCU). - While present in many cases of PUV, it indicates chronic obstruction rather than directly imaging the valves themselves. *Bladder neck contracture* - **Bladder neck contracture** is a narrowing at the exit of the bladder, which is a different anatomical obstruction than PUV. - The primary pathology in PUV is within the **posterior urethra**, distal to the bladder neck. *Vesico-Ureteric reflux* - **Vesico-ureteric reflux (VUR)** is the retrograde flow of urine from the bladder into the ureters and kidneys, which is a common associated finding with PUV due to the high bladder pressures. - While often seen in PUV, VUR is a complication or associated condition, not the direct diagnostic indicator of the valves themselves.

Question 4: Most common cause of urinary obstruction in a male infant is -

A. Stone
B. Anterior urethral valves
C. Stricture
D. Posterior urethral valves (Correct Answer)

Explanation: ***Posterior urethral valves*** - **Posterior urethral valves (PUV)** are the most common cause of significant **urinary tract obstruction** in male infants and are a congenital anomaly. - They are a membrane-like structure in the **posterior urethra** that obstructs urine outflow from the bladder. *Stone* - **Urinary stones** are a less common cause of obstruction in infants and are often associated with metabolic disorders or anatomical abnormalities. - While they can cause obstruction, they are not the most frequent cause in male infants. *Anterior urethral valves* - **Anterior urethral valves (AUV)** are a much rarer cause of urethral obstruction than PUV. - They occur more distally in the urethra and typically present with a **dilated anterior urethra**. *Stricture* - **Urethral strictures** in infants are usually acquired due to trauma, instrumentation, or infection, rather than being congenital. - They are less common than PUV as a primary cause of congenital urinary obstruction.

Question 5: Unilateral renal agenesis is associated with:

A. Hiatus Hernia
B. Single umbilical artery (Correct Answer)
C. Hypogonadism
D. Polycystic disease of pancreas

Explanation: ***Single umbilical artery*** - **Unilateral renal agenesis** is often associated with other congenital anomalies, including the presence of a **single umbilical artery** (2-vessel cord instead of the normal 3-vessel cord). - Both conditions can be part of **VACTERL association** (Vertebral, Anorectal, Cardiac, Tracheo-Esophageal, Renal, and Limb anomalies). - The **single umbilical artery** is a marker for increased risk of **urogenital and cardiovascular malformations**, which fits with renal agenesis. - Found in approximately **7-10% of cases with renal anomalies**. *Hiatus Hernia* - A **hiatal hernia** is a condition where part of the stomach pushes up through the diaphragm. - Not a recognized or common association with **unilateral renal agenesis**. - While it can be congenital, it arises from different developmental pathways than renal agenesis. *Hypogonadism* - **Hypogonadism** involves reduced function of the gonads and is not directly associated with **renal agenesis**. - Renal agenesis results from problems with the **metanephric blastema** and **ureteric bud** development, not the reproductive axis. *Polycystic disease of pancreas* - **Polycystic disease of the pancreas** is an extremely rare condition and does not have a well-established association with **unilateral renal agenesis**. - This should not be confused with **polycystic kidney disease**, which is a completely different entity.

Question 6: Reflux into grossly dilated ureter belongs to which grade of Vesicoureteric Reflux?

A. Grade V (Correct Answer)
B. Grade III
C. Grade II
D. Grade IV

Explanation: ***Grade V*** - **Grade V** VUR is characterized by reflux into a **grossly dilated** and tortuous ureter, often with blunting of the **renal calyces**. - This is the most severe form, indicating significant renal parenchymal damage risk and often associated with a non-functioning kidney. *Grade III* - **Grade III** VUR shows reflux into the ureter and renal pelvis, with **mild to moderate dilation** of the ureter and renal pelvis, but without blunting of the calyces. - The ureter is still relatively straight or mildly tortuous. *Grade II* - **Grade II** VUR involves reflux into the ureter, renal pelvis, and calyces, but without any **dilation** of these structures. - The reflux does not cause any anatomical changes to the kidney or ureter. *Grade IV* - **Grade IV** VUR presents with reflux into a **moderately dilated** and tortuous ureter, with moderate blunting of the **renal calyces**. - While significant, it is less severe than Grade V, which involves gross dilation and extensive calycial blunting.

Question 7: A one-year-old male child presented with a poor urinary stream since birth. The initial investigation of choice for evaluation is:

A. USG bladder
B. Voiding cystourethrography (VCUG) (Correct Answer)
C. Uroflowmetry
D. Intravenous urography

Explanation: ***Voiding cystourethrography (VCUG)*** - A **one-year-old male child with poor urinary stream since birth** is highly suggestive of **posterior urethral valves (PUV)**, the most common cause of bladder outlet obstruction in male infants. - **VCUG is the investigation of choice** for diagnosing PUV as it directly visualizes the posterior urethra during voiding and can demonstrate the characteristic findings: dilated posterior urethra, valve leaflets, bladder trabeculation, and vesicoureteral reflux. - While it involves catheterization and radiation, in this classic presentation, VCUG provides definitive diagnosis and is essential for surgical planning. *USG bladder* - Ultrasound is a useful **non-invasive screening tool** that can detect secondary findings such as hydronephrosis, bladder wall thickening, and increased post-void residual. - However, **USG cannot visualize the urethral valves** themselves and cannot definitively diagnose PUV. - In practice, many centers may perform ultrasound first, but it must be followed by VCUG for definitive diagnosis in this clinical scenario. *Uroflowmetry* - This test measures the **rate of urine flow** and requires patient cooperation with voiding. - A **one-year-old child cannot reliably follow instructions** to perform uroflowmetry. - It is more useful in older, cooperative children and adults. *Intravenous urography* - **Intravenous urography (IVU)** involves contrast administration and multiple X-rays to visualize the urinary tract. - It has been largely **replaced by ultrasound and CT urography** due to better imaging quality and safety profile. - IVU does not adequately visualize the urethra or diagnose urethral pathology like PUV.

Question 8: A three-year-old boy presents with a poor urinary stream. Most likely cause is -

A. Stricture urethra
B. Neurogenic bladder
C. Posterior urethral valve (Correct Answer)
D. Urethral calculus

Explanation: ***Posterior urethral valve*** - **Posterior urethral valve (PUV)** is the most common cause of **urethral obstruction** in male neonates and infants, leading to a poor urinary stream. - The obstruction is caused by abnormal folds of tissue in the **posterior urethra**, which impede urine flow from the bladder. *Stricture urethra* - While urethral strictures can cause a poor urinary stream, they are more commonly acquired through **trauma, infection, or instrumentation** and are less common in a 3-year-old boy as an initial presentation. - **Congenital urethral strictures** are rare and typically found more distally than PUV. *Neurogenic bladder* - **Neurogenic bladder** results from impaired neurological control over bladder function, leading to issues like poor stream, incontinence, or retention. - Although it can cause a poor stream, it is usually associated with other neurological signs or a history of **spinal cord anomalies** (e.g., myelomeningocele), which are not mentioned. *Urethral calculus* - **Urethral calculi** (stones) can obstruct urine flow and cause a poor stream, but they are relatively rare in a 3-year-old child without predisposing factors like metabolic abnormalities or recurrent urinary tract infections. - The presentation would typically include sudden onset of pain, hematuria, and potentially a history of prior stones.

Question 9: A neonate presenting with ascites is diagnosed with urinary ascites. What is the most common cause?

A. Bilateral PUJ obstruction
B. Infant polycystic kidney disease
C. Posterior urethral valve (Correct Answer)
D. Meatal stenosis

Explanation: ***Posterior urethral valve*** - **Posterior urethral valve (PUV)** is the most common cause of **urinary tract obstruction** in male neonates, leading to severe bladder outflow obstruction, often resulting in **urinary ascites** due to urinary extravasation. - The obstruction causes high pressure in the bladder and urinary tract, which can lead to rupture of the urinary system (e.g., bladder, renal pelvis, ureters) and leakage of urine into the peritoneal cavity. *Bilateral PUJ obstruction* - While **pelvic-ureteric junction (PUJ) obstruction** can cause hydronephrosis, bilateral obstruction leading to urinary ascites is less common than PUV. - PUJ obstruction primarily affects the flow of urine from the kidney to the ureter, and although severe, is less likely to cause widespread urinary extravasation into the peritoneum compared to distal urethral obstruction. *Infant polycystic kidney disease* - **Infant polycystic kidney disease (ARPKD)** is characterized by enlarged kidneys with numerous cysts, leading to renal dysfunction and often pulmonary hypoplasia. - While ARPKD can cause significant renal pathology, it does not typically lead to urinary ascites through obstructive mechanisms; ascites, if present, is usually due to liver fibrosis or heart failure, not urinary obstruction. *Meatal stenosis* - **Meatal stenosis** is a narrowing of the urethral opening, which can cause urinary obstruction but is usually a less severe and more distal obstruction compared to PUV. - It might cause symptoms like a thin stream or dysuria but is rarely severe enough in neonates to cause back pressure leading to urinary extravasation and ascites.

Question 10: A 1-month-old baby brought by the mother complaining of a mass on back associated with wetness and inability of both legs to move ever since birth. Possible diagnosis: (Recent NEET Pattern 2016-17)

A. Pilonidal cyst
B. Spina bifida
C. Meningomyelocele (Correct Answer)
D. Sacrococcygeal teratoma

Explanation: ***Meningomyelocele*** - This is a severe form of spina bifida where the **spinal cord and nerves protrude** through an opening in the back, encased in a fluid-filled sac. - The associated symptoms of a **mass on the back**, **wetness** (due to neurogenic bladder/bowel), and **inability to move both legs** (paralysis from nerve damage) are classic for meningomyelocele. *Pilonidal cyst* - A pilonidal cyst is usually a **small sinus or cyst** found at the top of the natal cleft (buttock crease) and is typically acquired or presents later in life. - While it can cause discharge/wetness if infected, it does **not cause neurological deficits** like leg paralysis in an infant. *Spina bifida* - Spina bifida is a broader term for a birth defect where there is **incomplete closing of the backbone and membranes around the spinal cord**. - While meningomyelocele is a type of spina bifida, and the symptoms fit, **meningomyelocele is a more specific and accurate diagnosis** given the description of a protruding mass and severe neurological deficits. *Sacrococcygeal teratoma* - A sacrococcygeal teratoma is a **tumor** that develops at the base of the tailbone, often appearing as a large mass. - While it's a mass on the back, it is typically a **solid or cystic tumor** and does not primarily present with wetness due to neurological incontinence or paralysis of the lower limbs.

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