Male Pelvic Imaging — MCQs

10 questions

Bell clapper deformity (abnormal testicular fixation) predisposes to which of the following conditions?

Gold standard investigation for breast carcinoma screening in a patient with silicone breast implants

A 40-year-old male visits a urologist and reports that for the past 2 weeks, his penis has been gradually curving to the right with associated pain during intercourse. He is able to have a normal erection and he does not recollect of any trauma to his penis. Although he is married, he admits to having unprotected sexual relationship with several females in the past year. His vitals are normal and physical examination is unremarkable except for a lesionless curved penis. It is painless to touch. Test results for sexually transmitted disease is pending. Which of the following is the most likely cause?

The most sensitive imaging modality to detect early renal tuberculosis is:

TRUS in carcinoma prostate is most useful for?

Transrectal ultrasonography in carcinoma prostate is most useful for –

A 20-year-old male presented to the emergency department with acute onset of pain in the right scrotum. On examination, the testes were swollen, and the transillumination test was negative. What could be the probable diagnosis based on the ultrasound of the scrotum?

Which of the following is the most serious complication of untreated urethral stricture?

Trendelenburg's sign is positive in injury to which structure?

Q10

A 35 year old nulliparous woman complains of menorrhagia and mass per abdomen. On examination, the positive findings are: she is anaemic, has a pelvic mass of 16-18 weeks size, firm in consistency which moves with the movement of cervix. What is the most likely clinical diagnosis?

Male Pelvic Imaging Indian Medical PG Practice Questions and MCQs

Question 1: Bell clapper deformity (abnormal testicular fixation) predisposes to which of the following conditions?

A. Hydrocele
B. Testicular torsion (Correct Answer)
C. Testicular atrophy
D. Varicocele

Explanation: ***Testicular torsion*** - The **bell clapper deformity** describes an abnormally high attachment of the tunica vaginalis, leaving the testis and epididymis free to rotate within the scrotal sac. - This anatomical variation allows the spermatic cord to twist, cutting off blood supply to the testis, which is the mechanism of **testicular torsion**. *Hydrocele* - A **hydrocele** is a collection of fluid in the tunica vaginalis, resulting from an imbalance in fluid production and absorption, or a patent processus vaginalis. - It is not directly caused by abnormal testicular fixation. *Testicular atrophy* - **Testicular atrophy** is a reduction in testicular size, often due to conditions like cryptorchidism, mumps orchitis, or prolonged testicular torsion, but not predisposed by the bell clapper deformity itself unless torsion occurs. - While torsion can lead to atrophy if not promptly treated, the deformity directly predisposes to the torsion event, rather than atrophy itself. *Varicocele* - A **varicocele** is an abnormal dilation of the veins of the pampiniform plexus within the scrotum, usually due to incompetent valves or venous obstruction. - This condition is not associated with testicular fixation abnormalities.

Question 2: Gold standard investigation for breast carcinoma screening in a patient with silicone breast implants

A. Mammography
B. CT scan
C. USG
D. MRI (Correct Answer)

Explanation: ***MRI*** - **MRI** is considered the **gold standard** for breast cancer screening in patients with silicone breast implants due to its superior ability to visualize breast tissue through the implant and detect subtle lesions. - It offers **high sensitivity** in detecting both implant rupture and early malignancies, often providing better clarity than mammography in augmented breasts where implants can obscure tissue. *Mammography* - While a standard screening tool, **mammography** can be limited in patients with silicone implants because the implants can **obscure adjacent breast tissue**, making detection of small masses challenging. - Special views (e.g., **Eklund views**) can be used, but sensitivity is still reduced compared to MRI in augmented breasts. *CT scan* - **CT scans** are not routinely used for primary breast cancer screening due to their use of **ionizing radiation** and lower sensitivity for detecting early breast lesions compared to MRI. - CT is more commonly used for **staging** advanced cancers or evaluating complex masses detected by other modalities. *USG* - **Ultrasound (USG)** is a valuable complementary tool, especially for evaluating palpable lumps or clarifying findings from mammography, but it is **operator-dependent** and has a lower overall sensitivity for general screening compared to MRI. - It is particularly useful for differentiating between **cystic and solid masses** and detecting implant ruptures but is not the gold standard for comprehensive screening in augmented breasts.

Question 3: A 40-year-old male visits a urologist and reports that for the past 2 weeks, his penis has been gradually curving to the right with associated pain during intercourse. He is able to have a normal erection and he does not recollect of any trauma to his penis. Although he is married, he admits to having unprotected sexual relationship with several females in the past year. His vitals are normal and physical examination is unremarkable except for a lesionless curved penis. It is painless to touch. Test results for sexually transmitted disease is pending. Which of the following is the most likely cause?

A. Fibrosis of corpus cavernosa
B. Congenital hypospadias
C. Hypertrophy of corpus cavernosa
D. Fibrosis of tunica albuginea (Correct Answer)
E. Syphilitic chancre

Explanation: ***Fibrosis of tunica albuginea*** - This presentation is highly suggestive of **Peyronie's disease**, characterized by **fibrous plaques** within the **tunica albuginea** of the penis, leading to penile curvature, pain, and sometimes erectile dysfunction. - The onset of **penile curvature** with associated pain during intercourse, without a history of trauma, points towards this condition, which is a localized fibrotic disorder. *Fibrosis of corpus cavernosa* - While fibrosis can occur in the corpus cavernosa, **Peyronie's disease specifically involves the tunica albuginea**, which is the fibrous sheath surrounding the erectile tissue. - Fibrosis within the corpus cavernosa itself might affect erectile function more broadly rather than causing a distinct curvature like that seen in Peyronie's. *Congenital hypospadias* - **Hypospadias** is a congenital condition where the **urethral opening is on the underside** of the penis, often associated with a ventral curvature (chordee). - This patient is 40 years old and reports recent onset of symptoms, indicating an **acquired condition**, not a congenital malformation that would have been present since birth. *Hypertrophy of corpus cavernosa* - **Hypertrophy** (enlargement) of the corpus cavernosa would likely cause a general increase in penile size or rigidity, but generally **would not lead to a localized curvature or pain** during erection. - Curvature is typically caused by asymmetric tissue changes, such as fibrosis, rather than uniform hypertrophy. *Syphilitic chancre* - A **syphilitic chancre** is a **painless ulcer** that often appears on the genitals and is a sign of primary syphilis. - Although the patient reports unprotected sexual encounters, a chancre is an **open lesion** and would not cause gradual penile curvature or pain during intercourse without other symptoms, and the physical examination was unremarkable except for the curvature.

Question 4: The most sensitive imaging modality to detect early renal tuberculosis is:

A. Intravenous urography
B. Magnetic resonance imaging (Correct Answer)
C. Ultrasound
D. Computed tomography

Explanation: ***Magnetic resonance imaging*** - **MRI** is the most sensitive imaging modality for detecting **early renal tuberculosis** due to its superior soft tissue contrast resolution. - It can identify subtle **parenchymal inflammatory changes**, early granulomas, and edema before calcification or cavitation occurs. - MRI is particularly useful for detecting **early renal cortical involvement** and small lesions that may be missed by other modalities. - Provides excellent anatomical detail without ionizing radiation. *Computed tomography* - **CT** is excellent for detecting **established renal tuberculosis** with calcifications, cavitations, and collecting system abnormalities. - However, calcifications and cavitations represent **intermediate to late findings**, not early disease. - CT is less sensitive than MRI for detecting subtle parenchymal inflammatory changes in early stages. - More useful once the disease has progressed to structural changes. *Ultrasound* - **Ultrasound** is useful for screening and follow-up but has significant limitations for early disease detection. - May miss small lesions, subtle parenchymal changes, and early calcifications. - Operator-dependent and limited by **acoustic windows** and patient body habitus. *Intravenous urography* - **IVU** primarily detects changes in the **collecting system** such as strictures, calyceal clubbing, and ureteral abnormalities. - These represent **late manifestations** of renal tuberculosis, not early disease. - Has largely been replaced by cross-sectional imaging (CT/MRI) for evaluating renal pathology. - Less sensitive for parenchymal involvement compared to CT or MRI.

Question 5: TRUS in carcinoma prostate is most useful for?

A. Evaluating nearby structures for involvement
B. Identifying suspicious areas in the prostate
C. Estimating the size of the prostate
D. Assisting in targeted prostate biopsies (Correct Answer)

Explanation: ***Assisting in targeted prostate biopsies*** - **TRUS** (Transrectal Ultrasound) provides real-time imaging, which is crucial for **guiding biopsy needles** accurately to suspicious areas within the prostate that may not be palpable. - This guidance increases the diagnostic yield of biopsies, ensuring samples are taken from potentially cancerous regions. *Evaluating nearby structures for involvement* - While TRUS can visualize the immediate surrounding structures like the **seminal vesicles**, its primary role is not for comprehensive staging of tumor extension outside the prostate, which is better achieved with MRI. - It helps in assessing direct invasion into seminal vesicles but has limitations for wider regional lymph node or distant metastasis evaluation. *Identifying suspicious areas in the prostate* - TRUS can identify **hypoechoic lesions** within the prostate, which are often associated with cancer, but these findings are not specific, and many benign conditions can mimic cancer. - The main utility is not solely in identifying these areas, but in using this identification to guide subsequent biopsies for definitive diagnosis. *Estimating the size of the prostate* - TRUS is highly effective for accurately measuring prostate volume, which is important for estimating PSA density and for surgical planning in benign prostatic hyperplasia (BPH). - However, while it can measure size, this is not its most diagnostically critical role in the context of carcinoma prostate when considering its unique capabilities.

Question 6: Transrectal ultrasonography in carcinoma prostate is most useful for –

A. To detect hypoechoic area
B. Seminal vesicle involvement
C. Measurement of prostatic volume
D. Guided prostatic biopsies (Correct Answer)

Explanation: ***Guided prostatic biopsies*** - **Transrectal ultrasonography (TRUS)** provides real-time visualization of the prostate, allowing for precise guidance during **prostatic biopsies**. - This guidance ensures that tissue samples are taken from suspicious areas, increasing the diagnostic yield for **prostate cancer**. *To detect hypoechoic area* - While TRUS can identify **hypoechoic areas** in the prostate, which may suggest malignancy, these are **not specific** to cancer and can be caused by other conditions like inflammation. - The primary utility of TRUS in prostate cancer is not merely detection of these areas, but rather using this information for targeted sampling. *Seminal vesicle involvement* - TRUS can visualize the seminal vesicles, but its accuracy in definitively determining **seminal vesicle invasion** is limited compared to more advanced imaging like **MRI**. - **MRI** is generally preferred for assessing extraprostatic extension and seminal vesicle involvement due to its superior soft tissue contrast. *Measurement of prostatic volume* - TRUS is used to measure **prostatic volume**, which is important for calculating **PSA density** and for treatment planning in benign prostatic hyperplasia (BPH). - However, in the context of prostate cancer, while volume measurement is possible, guided biopsy is its most crucial role for diagnosis.

Question 7: A 20-year-old male presented to the emergency department with acute onset of pain in the right scrotum. On examination, the testes were swollen, and the transillumination test was negative. What could be the probable diagnosis based on the ultrasound of the scrotum?

A. Acute epididymitis
B. Testicular torsion (Correct Answer)
C. Fournier's syndrome
D. Hydrocele

Explanation: ***Testicular torsion*** - The ultrasound image shows a significant **lack of blood flow** (absent or markedly decreased color flow signals) in the right testis compared to the left, which is characteristic of **testicular torsion**. - **Acute onset of pain**, swollen testis, and a **negative transillumination test** in a young male are clinical signs highly suggestive of testicular torsion, requiring urgent intervention. *Fournier's syndrome* - This is a severe form of **necrotizing fasciitis** of the perineum and genitals, typically presenting with crepitus, gangrene, and systemic symptoms, which are not described. - Ultrasound would show gas in the soft tissues and possibly fluid collections, not primarily compromised testicular blood flow within the testis itself. *Acute epididymitis* - Acute epididymitis would typically show **increased blood flow** (hyperemia) in the affected epididymis and potentially the testis on Doppler ultrasound. - While it causes acute scrotal pain and swelling, the key differentiator here is the **absent/decreased blood flow** on the ultrasound, which rules out epididymitis. *Hydrocele* - A hydrocele is a collection of **fluid around the testis**, which would appear as an anechoic (black) fluid collection on ultrasound. - A hydrocele typically would yield a **positive transillumination test** and does not usually cause acute, severe pain or lead to a significant change in testicular blood flow on Doppler like torsion does.

Question 8: Which of the following is the most serious complication of untreated urethral stricture?

A. Periurethral abscess (Correct Answer)
B. Urethral diverticulum
C. Retention of urine
D. All of these

Explanation: ***Periurethral abscess*** - An untreated urethral stricture can lead to urinary stasis and infection, which can then progress to a **periurethral abscess**. - A periurethral abscess is a serious localized collection of pus that can rupture internally or externally, causing severe pain, infection, and potentially necessitating complex surgical intervention. *Urethral diverticulum* - While urethral strictures can contribute to the formation of a **urethral diverticulum** due to increased pressure and obstruction, it is generally considered a less immediate and life-threatening complication compared to an abscess. - A diverticulum is an outpouching of the urethra, which can cause symptoms like dysuria, recurrent UTIs, and post-void dribbling, but does not typically pose the same acute infectious risk as an abscess. *Retention of urine* - **Urinary retention** is a common and significant symptom of a urethral stricture, as the narrowing blocks the flow of urine. - While uncomfortable and requiring intervention, acute urinary retention itself is usually manageable with catheterization and does not carry the same degree of tissue destruction and systemic infection risk as a periurethral abscess. *All of these* - While all listed options can be complications of an untreated urethral stricture, **periurethral abscess** represents the most serious due to its potential for severe infection, tissue destruction, and more complex management. - The question asks for the **most serious** complication, which points to the one with the highest morbidity and potential for systemic consequences.

Question 9: Trendelenburg's sign is positive in injury to which structure?

A. Gluteus maximus
B. Gluteus medius (Correct Answer)
C. Quadriceps femoris
D. Quadratus lumborum

Explanation: ***Gluteus medius*** - A positive **Trendelenburg's sign** indicates weakness or paralysis of the **gluteus medius** muscle, or problem with its innervation or hip joint. - This muscle is crucial for **abduction** and **stabilization** of the pelvis during gait; its dysfunction causes the unsupported side of the pelvis to drop. *Gluteus maximus* - The **gluteus maximus** is primarily involved in **hip extension** and external rotation, not hip abduction or pelvic stability during single-leg stance. - Weakness in this muscle would manifest more as difficulty with climbing stairs or rising from a seated position. *Quadriceps femoris* - The **quadriceps femoris** muscles are responsible for **knee extension**, essential for walking and standing. - Injury to these muscles would primarily affect the ability to **straighten the leg** and bear weight on it, not cause pelvic drop. *Quadratus lumborum* - The **quadratus lumborum** is a deep abdominal muscle involved in **lateral flexion of the trunk** and stabilization of the lumbar spine. - Dysfunction of this muscle would lead to **trunk instability** or pain, but not the specific pelvic drop seen in Trendelenburg's sign.

Question 10: A 35 year old nulliparous woman complains of menorrhagia and mass per abdomen. On examination, the positive findings are: she is anaemic, has a pelvic mass of 16-18 weeks size, firm in consistency which moves with the movement of cervix. What is the most likely clinical diagnosis?

A. Leiomyoma (Correct Answer)
B. Adenomyosis
C. Ovarian tumour
D. Endometrial carcinoma

Explanation: ***Leiomyoma*** - A **leiomyoma**, or **fibroid**, is a common benign smooth muscle tumor of the uterus, often presenting as **menorrhagia** and a **pelvic mass**. - The mass being **firm, 16-18 weeks size**, and **moving with the cervix** is classic for a uterine fibroid, differentiating it from an adnexal or fixed uterine mass. *Adenomyosis* - Characterized by endometrial tissue within the myometrium, leading to a **globular, tender uterus**, often associated with **dysmenorrhea** and **menorrhagia**. - While it causes menorrhagia, the uterus is typically **tender** and **boggy**, not a firm, discrete mass freely mobile with the cervix. *Ovarian tumour* - An **ovarian tumor** would typically present as an **adnexal mass**, often separate from the uterus and not moving with the cervix. - While an ovarian tumor can cause a pelvic mass, it is less likely to be directly associated with the described menorrhagia or involve the cervix's movement. *Endometrial carcinoma* - Primarily causes **abnormal uterine bleeding**, especially in **postmenopausal women**, but usually does not present as a large, firm, mobile mass detectable on abdominal palpation. - While it can cause menorrhagia, a firm, discrete uterine mass that moves with the cervix is not a typical presentation of **endometrial carcinoma**.

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