Genitourinary Trauma — MCQs
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-
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
What is the treatment for most cases of blunt trauma to the kidney?
Mr. Ramu, a 35-year-old male, sustained a straddle injury in a motor vehicle accident and presents to the emergency department with blood at the urethral meatus. What is the next appropriate step in his management?
Young male with history of trauma having left sided testis swollen and erythematous. Other side normal. What is the diagnosis?
Following road traffic accident, a patient with vague abdominal pain was immediately taken to the operation theatre for emergency laparotomy. On examination, a large, contained, stable, non-pulsatile retroperitoneal hematoma was found on the right side. One-shot IVU shows a barely discernible nephrogram on the right side and prompt uptake and excretion on the left side. What should be the next step to be done?
A person could not pass urine after a fall shown below. On examination vitals are stable but bladder is palpable. What is the probable diagnosis? (NEET Pattern 2018)
Most common cause of acquired atrioventricular fistula is -
Genitourinary Trauma Indian Medical PG Practice Questions and MCQs
Question 1: 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 2: 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 3: 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 4: 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 5: What is the treatment for most cases of blunt trauma to the kidney?
- A. Conservative (Correct Answer)
- B. Nephrectomy
- C. Nephrotomy
- D. Nephroplexy
Explanation: ***Conservative*** - The majority of kidney injuries resulting from **blunt trauma** are low-grade (Grades I-III) and can be successfully managed with **conservative (non-operative) methods**. - This typically involves bed rest, careful monitoring of vital signs and urine output, hydration, and serial imaging to ensure stability and healing of the kidney. *Nephrectomy* - **Nephrectomy** (surgical removal of the kidney) is generally reserved for severe, high-grade kidney injuries (Grades IV-V) that are life-threatening or cannot be controlled by other means. - Indications include uncontrollable hemorrhage, extensive renal parenchymal destruction, or a non-viable kidney. *Nephrotomy* - **Nephrotomy** is an incision into the kidney, often performed for stone removal or to drain an abscess, but it is not a primary treatment for blunt traumatic kidney injury. - While surgical repair (nephrorrhaphy) may sometimes be indicated for high-grade injuries to preserve the kidney, a simple nephrotomy is not the standard approach. *Nephroplexy* - **Nephroplexy** is a surgical procedure to fix a prolapsed or "floating" kidney (nephroptosis), which is an entirely different condition from traumatic injury. - This procedure aims to secure the kidney in its normal anatomical position and is not indicated for kidney trauma.
Question 6: Mr. Ramu, a 35-year-old male, sustained a straddle injury in a motor vehicle accident and presents to the emergency department with blood at the urethral meatus. What is the next appropriate step in his management?
- A. CECT Abdomen
- B. FAST
- C. Abdomen X-ray
- D. Retrograde urethrogram (Correct Answer)
Explanation: ***Retrograde urethrogram*** - **Blood at the urethral meatus** after a straddle injury is highly suggestive of **urethral injury**, and a retrograde urethrogram is the diagnostic test of choice to assess the integrity of the urethra. - This procedure involves injecting contrast into the urethra to visualize any extravasation, strictures, or complete disruptions before attempting catheterization. *CECT Abdomen* - A CECT abdomen is primarily used to assess **solid organ injuries** or **intra-abdominal bleeding**, which is not the primary concern suggested by blood at the urethral meatus. - While broad abdominal trauma may warrant a CECT, it does not directly evaluate urethral integrity. *FAST* - **FAST (Focused Assessment with Sonography for Trauma)** is a rapid ultrasound examination to detect **free fluid (blood)** in the peritoneal or pericardial cavities. - It is used to identify **intra-abdominal or pericardial hemorrhage** and guide resuscitation, but it does not visualize the urethra. *Abdomen X-ray* - An abdomen X-ray can detect **fractures of the pelvis** or foreign bodies, but it does not provide detailed imaging of soft tissues like the urethra. - It would not show urethral extravasation or disruption, making it insufficient for diagnosing urethral injury.
Question 7: 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 8: Following road traffic accident, a patient with vague abdominal pain was immediately taken to the operation theatre for emergency laparotomy. On examination, a large, contained, stable, non-pulsatile retroperitoneal hematoma was found on the right side. One-shot IVU shows a barely discernible nephrogram on the right side and prompt uptake and excretion on the left side. What should be the next step to be done?
- A. Isolate the proximal renal vessels, open the Gerota's fascia and explore the kidney (Correct Answer)
- B. Nephrectomy
- C. Perform on table retrograde pyelography
- D. Perform on table angiography
Explanation: ***Isolate the proximal renal vessels, open the Gerota's fascia and explore the kidney*** - While **Zone II (lateral/perirenal) retroperitoneal hematomas** are generally NOT explored if stable, contained, and non-pulsatile, this case has a critical exception. - The **barely discernible nephrogram on IVU** suggests severe renal parenchymal or vascular injury, indicating the kidney may not be viable. - In the setting of a **non-functioning or poorly functioning kidney** (as evidenced by the IVU), exploration is warranted to assess salvageability. - The correct approach is to **first isolate the proximal renal vessels** (achieve vascular control) before opening Gerota's fascia to prevent uncontrolled hemorrhage during exploration. - This allows for **attempted renal salvage** or controlled nephrectomy if the kidney is non-salvageable. *Nephrectomy* - This is premature without first exploring to assess the extent of injury. - While the barely discernible nephrogram is concerning, immediate nephrectomy without exploration may remove a potentially salvageable kidney. - Nephrectomy should only be performed after exploration confirms **irreparable damage** or if hemorrhage cannot be controlled. *Perform on table retrograde pyelography* - Retrograde pyelography primarily evaluates the **collecting system and ureter** for injury or extravasation. - In this case, the main concern is **renal parenchymal or vascular injury** (suggested by the poor nephrogram), not collecting system injury. - This would delay definitive management and does not address the question of renal viability. - Retrograde pyelography is more useful when IVU is non-diagnostic and ureteral injury is suspected. *Perform on table angiography* - While angiography can identify **vascular injuries** and is valuable in stable patients, it is typically not performed on the operating table during emergency laparotomy. - The patient is already in the OR with an open abdomen, making direct surgical exploration more practical than angiography. - Angiography with possible **angioembolization** is more appropriate for stable patients managed non-operatively or in delayed settings.
Question 9: A person could not pass urine after a fall shown below. On examination vitals are stable but bladder is palpable. What is the probable diagnosis? (NEET Pattern 2018)
- A. Anterior urethra rupture
- B. Posterior urethra rupture (Correct Answer)
- C. Penile avulsion
- D. Recto-urethral injury
Explanation: ***Posterior urethra rupture*** - The mechanism of injury, a **fall causing blunt perineal trauma** (as depicted by the man falling into a manhole), is a classic cause of posterior urethral injury, often associated with **pelvic fractures**. - The inability to pass urine with a **palpable distended bladder** indicates urinary retention due to complete urethral disruption, preventing urine flow from the bladder. - Classical triad: inability to void, blood at urethral meatus, and palpable bladder. *Anterior urethra rupture* - This typically results from a "straddle injury" (e.g., falling astride a beam or bike bar), which is different from the fall shown. - Anterior urethral injuries often manifest with **perineal extravasation of urine and blood (butterfly hematoma)**, and the bladder might still be palpable if retention occurs. *Penile avulsion* - This is a severe injury involving the **tearing away of penile skin or the entire penis**, which is not immediately suggested by the described symptoms of inability to urinate. - It would present with **obvious external hemorrhage** and tissue loss, not just urinary retention. *Recto-urethral injury* - This involves damage to both the **rectum and urethra**, usually from penetrating trauma or severe crush injuries. - While it could cause dysuria or inability to urinate, it would also likely present with **rectal bleeding or a palpable rectal injury**, which is not mentioned in the clinical scenario.
Question 10: Most common cause of acquired atrioventricular fistula is -
- A. Bacterial infection
- B. Fungal infection
- C. Penetrating trauma (Correct Answer)
- D. Blunt trauma
Explanation: ***Penetrating trauma*** - **Penetrating injuries**, such as stab wounds or gunshot wounds to the chest, are the most frequent cause of **acquired atrioventricular fistulas**. - These injuries can directly transect or damage the walls of adjacent cardiac chambers and great vessels, creating an abnormal communication. *Bacterial infection* - While bacterial infections can lead to conditions like **endocarditis** or abscess formation, they are not the most common direct cause of an **acquired atrioventricular fistula**. - Endocarditis primarily involves valve damage and can rarely extend to form fistulas, but this is less frequent than trauma. *Fungal infection* - Fungal infections, especially in immunocompromised individuals, can cause **mycotic aneurysms** or severe endocarditis. - However, they are a rare cause of direct **atrioventricular fistula formation** compared to traumatic injuries. *Blunt trauma* - **Blunt chest trauma** can cause myocardial contusion, rupture of cardiac chambers, or vessel dissection. - While severe blunt trauma can lead to cardiac injury, it is less likely to create a discrete **atrioventricular fistula** than a sharp penetrating injury that punctures both structures.
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