Genitourinary Trauma — MCQs

10 questions

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?

Examine the abdominal X-ray shown. What is the most likely diagnosis based on the findings?

The most appropriate investigation to diagnose and determine the extent of renal injury in a 15-year-old boy who presents with hematuria and left-sided abdominal pain 48 hours after sustaining a blunt abdominal injury, with a pulse rate of 96/minute, blood pressure of 110/70 mmHg, hemoglobin of 10.8 gm%, and packed cell volume of 31%, would be-

Young male with history of trauma having left sided testis swollen and erythematous. Other side normal. What is the diagnosis?

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:

A person after a pelvic fracture, could not pass urine. On examination bladder is not palpable. What is the probable diagnosis?

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

A patient is seen on the second postoperative day after a difficult abdominal hysterectomy complicated by ureteral injury during ligation of the left uterine artery pedicle. The patient has developed sepsis. If the ureteral injury had been recognized at the time of surgery, which of the following procedures could have been recommended?

All of the following are true regarding renal trauma, except which of the following?

Q10

True about chest trauma:

Genitourinary Trauma Indian Medical PG Practice Questions and MCQs

Question 1: 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?

A. Membranous urethra
B. Prostatic urethra
C. Bulbar urethra (Correct Answer)
D. Bladder

Explanation: ***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 2: Examine the abdominal X-ray shown. What is the most likely diagnosis based on the findings?

A. Small bowel ileus
B. Pneumoperitoneum
C. Intestinal Obstruction (Correct Answer)
D. Large bowel obstruction

Explanation: ***Intestinal Obstruction*** - The abdominal X-ray demonstrates **distended loops of bowel** with **multiple air-fluid levels**, which are classic radiographic signs of intestinal obstruction. - The presence of multiple, wide air-fluid levels visible in a **stepladder pattern** is a hallmark of bowel obstruction. - **Valvulae conniventes** (transverse folds crossing the entire width of bowel) suggest **small bowel** involvement when visible with distension. *Small bowel ileus* - While ileus can show distended bowel loops, it typically presents with **gas distributed throughout the small and large bowel** without a clear transition point. - Ileus shows **less pronounced air-fluid levels** and lacks the characteristic stepladder pattern seen in mechanical obstruction. - The clinical context and presence of multiple distinct air-fluid levels favor mechanical obstruction over ileus. *Large bowel obstruction* - Large bowel obstruction would show **dilated colon** with **haustrations** (incomplete folds that don't cross the entire lumen). - The obstruction would typically show dilation **proximal to the obstruction** with collapsed bowel distally. - The pattern in this image is more consistent with small bowel or generalized intestinal obstruction rather than isolated large bowel obstruction. *Pneumoperitoneum* - Pneumoperitoneum (free air in the peritoneal cavity) appears as **air under the diaphragm** on upright films or as **Rigler's sign** (both sides of bowel wall visible) on supine films. - This is a sign of **bowel perforation**, not obstruction with air-fluid levels within the bowel lumen. - The air-fluid levels seen here are **intraluminal**, not free intraperitoneal air.

Question 3: The most appropriate investigation to diagnose and determine the extent of renal injury in a 15-year-old boy who presents with hematuria and left-sided abdominal pain 48 hours after sustaining a blunt abdominal injury, with a pulse rate of 96/minute, blood pressure of 110/70 mmHg, hemoglobin of 10.8 gm%, and packed cell volume of 31%, would be-

A. Sonographic evaluation of abdomen
B. Intravenous pyelography
C. Contrast enhanced computed tomography (Correct Answer)
D. MR urography

Explanation: ***Contrast enhanced computed tomography*** - **CT with intravenous contrast** is the gold standard for evaluating **renal trauma**, providing detailed anatomical information on the extent of injury, including lacerations, hematomas, and urinary extravasation, which might be missed by other modalities. - It rapidly assesses the **parenchyma**, **collecting system**, and surrounding structures, allowing for proper staging of the injury and guiding management decisions. *Sonographic evaluation of abdomen* - **Ultrasound** is useful for rapidly detecting **free fluid** (e.g., blood) in the abdomen and assessing major organ integrity, but its ability to characterize renal parenchymal injuries or urinary extravasation is limited. - It is **operator-dependent** and often insufficient for detailed staging of renal trauma compared to CT. *Intravenous pyelography* - **IVP** primarily evaluates the **collecting system** and ureteral patency but has limited sensitivity for assessing renal parenchymal injuries or perinephric hematomas. - It involves radiation exposure and a contrast load, and generally provides **less anatomical detail** than modern CT scans. *MR urography* - **MR urography** provides excellent soft tissue contrast without ionizing radiation, but it is typically **less readily available** in an emergency setting and takes longer to perform than CT. - Its role in acute trauma is usually reserved for cases where **iodinated contrast is contraindicated** (e.g., severe allergy, renal insufficiency) or when specific soft-tissue detail is crucial for follow-up.

Question 4: Young male with history of trauma having left sided testis swollen and erythematous. Other side normal. What is the diagnosis?

A. Carcinoma
B. Hernia
C. Hematoma (Correct Answer)
D. Torsion

Explanation: ***Hematoma*** - A history of **trauma** leading to a **swollen and erythematous testis** is highly indicative of a testicular hematoma. Trauma can cause bleeding within the scrotal sac, leading to the observed symptoms. - A hematoma is a localized collection of **blood outside of blood vessels**, which in this case, results from the injury to the testis or surrounding structures. *Torsion* - Testicular torsion typically presents with **sudden, severe pain** and swelling, and can be associated with absent **cremasteric reflex**. While swelling is present, the clear history of trauma points away from spontaneous torsion. - Torsion is an **emergency** caused by the twisting of the spermatic cord, which **cuts off blood supply** to the testis, and usually lacks a direct antecedent trauma. *Carcinoma* - Testicular carcinoma usually presents as a **painless, firm mass** within the testis. Pain can occur if there is hemorrhage within the tumor or rapid growth. - While it can cause swelling, the acute onset and direct association with trauma make carcinoma less likely, as it is a **slowly progressive** condition. *Hernia* - An inguinal hernia typically presents as a **groin bulge** that can extend into the scrotum, and usually reduces with manipulation or lying down. It is often associated with a cough or strain. - While a hernia can cause scrotal swelling, the primary presentation is usually a reducible mass, and the direct link to trauma with associated erythema is not typical for a simple hernia.

Question 5: 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:

A. Retrograde urethrography should be done after the patient is stabilized
B. Rectal examination may reveal a large pelvic hematoma
C. Anterior urethra is the most likely site of injury (Correct Answer)
D. Foley catheter may be carefully passed if the RGU is normal

Explanation: ***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.

Question 6: A person after a pelvic fracture, could not pass urine. On examination bladder is not palpable. What is the probable diagnosis?

A. Extraperitoneal rupture of bladder (Correct Answer)
B. Intraperitoneal rupture of bladder
C. Rectourethral injury
D. Posterior urethra rupture with retention of urine

Explanation: ***Extraperitoneal rupture of bladder*** - This typically occurs with **pelvic fractures**, especially pubic rami fractures, as the bony fragments can lacerate the bladder wall outside the peritoneum. - The inability to pass urine and a **non-palpable bladder** suggest that urine has escaped into the surrounding tissues, but not into the peritoneal cavity, and is not distending the bladder. *Intraperitoneal rupture of bladder* - Usually results from a **direct blow to a full bladder**, rather than a pelvic fracture, causing urine to spill into the peritoneal cavity. - While there would be an inability to pass urine, the bladder would likely be **distended and palpable** initially, or there would be signs of peritonitis. *Rectourethral injury* - This involves a tear between the rectum and the urethra, often associated with severe pelvic trauma. - While it causes an inability to void, the primary concern would be **fecal leakage into the urethra** or urinary leakage into the rectum, not necessarily a non-palpable bladder due to rupture into surrounding tissues. *Posterior urethra rupture with retention of urine* - A rupture of the posterior urethra, common with pelvic fractures, would indeed cause **retention of urine** and an inability to void. - However, in this scenario, the bladder would be **distended and palpable** above the symphysis pubis due to the retained urine, which contradicts the "non-palpable bladder" finding.

Question 7: 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

A. Bulbar urethral injury
B. Bladder rupture
C. Kidney laceration
D. Rupture of membranous urethra (Correct Answer)

Explanation: ***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.

Question 8: A patient is seen on the second postoperative day after a difficult abdominal hysterectomy complicated by ureteral injury during ligation of the left uterine artery pedicle. The patient has developed sepsis. If the ureteral injury had been recognized at the time of surgery, which of the following procedures could have been recommended?

A. Placement of a ureteral stent without anastomosis
B. Ureteral reimplantation into the bladder (Correct Answer)
C. Percutaneous nephrostomy
D. Ureteroureteral anastomosis

Explanation: ***Ureteral reimplantation into the bladder*** - For a **distal ureteral injury** near the bladder, as would likely occur during a hysterectomy involving the uterine artery pedicle, **ureteral reimplantation** directly into the bladder (ureteroneocystostomy) is the reconstructive procedure of choice. - This method provides a **robust and long-lasting repair**, typically performed acutely when the injury is recognized immediately during surgery. *Placement of a ureteral stent without anastomosis* - This is an insufficient intervention for a **frank transection or significant injury** to the ureter; a stent alone cannot repair a severed ureter. - Stents are typically used for **intraluminal obstruction** or to protect an anastomosis, not as a solitary treatment for a complete ureteral injury. *Percutaneous nephrostomy* - This procedure diverts urine from the kidney externally and is primarily used for **temporary drainage** in cases of ureteral obstruction, fistula, or severe sepsis/urosepsis to protect kidney function, often as a temporizing measure before definitive repair. - It does not **repair the ureteral injury** itself, making it an inappropriate direct surgical solution if the injury is recognized and can be repaired at the time of surgery. *Ureteroureteral anastomosis* - This involves **reconnecting the two ends of a severed ureter** but is generally reserved for **mid-ureteral injuries** or when there is sufficient length to achieve a tension-free repair. - Given the injury near the uterine artery pedicle during a hysterectomy, it is more likely to be a **distal ureteral injury**, where reimplantation into the bladder is usually preferred due to shorter mobilized segments and better long-term patency rates.

Question 9: All of the following are true regarding renal trauma, except which of the following?

A. Observation is best
B. Exploration indicated in all cases (Correct Answer)
C. Haematuria is a cardinal sign
D. CECT is the investigation of choice

Explanation: ***Exploration indicated in all cases*** - This statement is incorrect because not all renal traumas require **surgical exploration**. Many low-grade renal injuries can be managed **conservatively** with observation. - The decision for exploration depends on the **grade of injury**, hemodynamic stability, and associated injuries. **Absolute indications** for exploration include: hemodynamic instability despite resuscitation, expanding/pulsatile perirenal hematoma, and renal pedicle avulsion. - Approximately **80-90% of renal traumas** are managed non-operatively. *Observation is best* - This is true for **low-grade renal injuries (Grade I-III)**, especially in hemodynamically stable patients. - **Conservative management** with bed rest, fluid resuscitation, serial hemoglobin monitoring, and close observation is the preferred approach for most renal traumas that do not involve major vascular injury or ongoing hemorrhage. *CECT is the investigation of choice* - **Contrast-Enhanced CT (CECT)** is the **gold standard** imaging modality for evaluating renal trauma in hemodynamically stable patients. - It provides detailed information about the **grade of injury**, renal parenchymal damage, collecting system involvement, urinary extravasation, and vascular injuries. - CECT helps in **injury grading** (AAST classification) and guides management decisions regarding conservative vs. operative management. *Haematuria is a cardinal sign* - **Hematuria (blood in the urine)** is indeed a cardinal sign of renal trauma and is present in **over 90% of cases**. - The presence of gross or microscopic hematuria after blunt or penetrating abdominal trauma warrants investigation for potential renal injury. - **Important:** The degree of hematuria does NOT correlate with the severity of injury. Severe injuries like renal pedicle avulsion may present with minimal or absent hematuria.

Question 10: True about chest trauma:

A. All of the options
B. ECG done in all cases associated with sternal fracture (Correct Answer)
C. Urgent surgery needed in all cases
D. Under water seal drainage if associated with pneumothorax. X-ray chest investigation of choice

Explanation: ***ECG done in all cases associated with sternal fracture*** - A **sternal fracture** is a significant injury often caused by high-impact trauma, which can lead to **myocardial contusion** or other cardiac injuries. - An **ECG** is **mandatory** in all cases of sternal fracture for detecting potential cardiac involvement, such as **arrhythmias** or **ischemic changes**, indicating underlying myocardial damage. - This is a clear, unequivocal true statement about chest trauma management and the **best answer**. *All of the options* - This option is incorrect because not all statements provided are true or represent best practices in chest trauma management. - Specifically, "urgent surgery needed in all cases" is clearly false, making this option incorrect. *Urgent surgery needed in all cases* - This statement is **false**. Approximately **80-85% of chest trauma** cases are managed **non-operatively** with supportive care. - Urgent surgery is required only in specific situations: **massive hemothorax**, **cardiac tamponade**, **major airway injury**, **esophageal perforation**, or ongoing bleeding. - Simple rib fractures, minor pneumothorax, and pulmonary contusions rarely require surgery. *Under water seal drainage if associated with pneumothorax. X-ray chest investigation of choice* - While both components of this statement are individually true, the option combines two separate management concepts without clear connection. - **Underwater seal drainage (chest tube)** is indeed appropriate for significant pneumothorax, and **chest X-ray** is the initial investigation of choice for chest trauma. - However, this option is less precise than Option B, which states an absolute management protocol, making Option B the superior choice.

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