Hematuria Evaluation — MCQs
A woman presents to you with fever, arthralgia, ulcers, fatigue for the past six months, and new-onset hematuria. Urine examination reveals RBC casts and proteinuria. What is the likely diagnosis?
An asymptomatic patient has proteinuria and hematuria that is glomerular in origin on a routine urinalysis. Which of the following is the most likely diagnosis?
A 5 year child is brought with brown coloured urine and oliguria since 3 days with mild facial puffiness and pedal edema with 3+ proteinuria, BP 126/90. Urine examination shows RBCs 100/hpf and granular casts. Which of the following doesn't present with this finding?
What is the investigation of choice in a patient with blunt abdominal trauma with hematuria?
A 27-year-old woman presents with 26 weeks of gestation with a thyroid lesion which is found to be papillary carcinoma of thyroid. Which is the best treatment for this patient?
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?
What is the most common site for extramammary Paget's disease?
Regarding ectopia vesicae, which of the following is true EXCEPT?
What is the first-line treatment for overactive bladder?
Subcapsular orchiectomy is done for cancer of which organ?
Hematuria Evaluation Indian Medical PG Practice Questions and MCQs
Question 1: A woman presents to you with fever, arthralgia, ulcers, fatigue for the past six months, and new-onset hematuria. Urine examination reveals RBC casts and proteinuria. What is the likely diagnosis?
- A. Acute interstitial nephritis
- B. Poststreptococcal glomerulonephritis
- C. Lupus nephritis (Correct Answer)
- D. IgA nephropathy
Explanation: ***Lupus nephritis*** - The combination of **fever, arthralgia, oral ulcers, and fatigue** lasting for six months is highly suggestive of **systemic lupus erythematosus (SLE)** [1]. - The new-onset **hematuria, proteinuria, and RBC casts** indicate **glomerulonephritis**, which is a common and serious renal manifestation of SLE, known as lupus nephritis [2]. *Acute interstitial nephritis* - Characterized by acute kidney injury, often following exposure to **medications** (e.g., NSAIDs, antibiotics) or infections. - Typically presents with sterile pyuria, eosinophilia, and white cell casts, not hemorrhagic urine and RBC casts. *Poststreptococcal glomerulonephritis* - Occurs **1-3 weeks after a streptococcal infection** (e.g., pharyngitis, impetigo) and presents with acute nephritic syndrome. - While it causes hematuria and proteinuria, the prolonged systemic symptoms (arthralgia, ulcers, fatigue) and the absence of a recent streptococcal infection make it less likely. *IgA nephropathy* - Often presents with **recurrent episodes of gross hematuria**, usually developing within days of an upper respiratory tract infection. - It does not typically present with the broad array of systemic symptoms like chronic fever, arthralgia, and oral ulcers seen in this patient.
Question 2: An asymptomatic patient has proteinuria and hematuria that is glomerular in origin on a routine urinalysis. Which of the following is the most likely diagnosis?
- A. immunoglobulin A (IgA) nephropathy (Berger's disease) (Correct Answer)
- B. diabetes mellitus (DM) - nephropathy
- C. amyloidosis - nephropathy
- D. focal glomerulosclerosis - nephropathy
Explanation: ***immunoglobulin A (IgA) nephropathy (Berger's disease)*** - **IgA nephropathy** often presents with **asymptomatic gross or microscopic hematuria** and proteinuria, which can be glomerular in origin [1]. - It is one of the most common causes of **glomerular hematuria** and can be discovered incidentally on routine urinalysis [1]. *diabetes mellitus (DM) - nephropathy* - While **diabetic nephropathy** causes proteinuria, **hematuria is not a primary or prominent feature** in the early stages; it typically presents with progressive proteinuria and kidney function decline [2]. - Patients with **diabetic nephropathy** are usually symptomatic with **long-standing diabetes** and often associated complications. *amyloidosis - nephropathy* - **Nephropathy due to amyloidosis** primarily presents with **heavy proteinuria**, leading to **nephrotic syndrome**, but hematuria is uncommon. - Systemic amyloidosis often involves other organs, and patients typically present with other associated symptoms like **fatigue, weight loss, or organ dysfunction**. *focal glomerulosclerosis - nephropathy* - **Focal segmental glomerulosclerosis (FSGS)** typically presents with **nephrotic syndrome** (heavy proteinuria, edema, hypoalbuminemia), with microscopic hematuria being inconsistent and often mild. - While it can be primary (idiopathic), it more commonly presents with symptoms of **nephrotic range proteinuria** rather than isolated asymptomatic hematuria and proteinuria.
Question 3: A 5 year child is brought with brown coloured urine and oliguria since 3 days with mild facial puffiness and pedal edema with 3+ proteinuria, BP 126/90. Urine examination shows RBCs 100/hpf and granular casts. Which of the following doesn't present with this finding?
- A. FSGS
- B. Membranous glomerulonephritis
- C. Minimal change disease (Correct Answer)
- D. IgA nephropathy
Explanation: ***Minimal change disease*** - This condition is the most common cause of **nephrotic syndrome** in children, characterized by **marked proteinuria**, **edema**, and **normal renal function**. - It typically does **NOT** present with **hematuria**, **hypertension**, or **red blood cell casts** in the urine, which are prominent features in this case. - MCD presents with **pure nephrotic syndrome** without nephritic features, making it the condition that doesn't match this clinical presentation. *FSGS* - **Focal segmental glomerulosclerosis (FSGS)** can present with a **mixed nephrotic-nephritic picture**, including significant **proteinuria**, **hematuria**, and **hypertension**. - The presence of **RBC casts** and **hypertension** is consistent with FSGS, which can show inflammatory glomerular changes. *Membranous glomerulonephritis* - **Membranous glomerulonephritis (MGN)** primarily causes **nephrotic syndrome** in adults but can occur in children. - While MGN predominantly presents with **proteinuria** and **edema**, it can occasionally have **microscopic hematuria** and mild **hypertension**. - The prominent **nephritic features** (marked hematuria, RBC casts, oliguria) make MGN less likely but not impossible in this case. *IgA nephropathy* - **IgA nephropathy** is the **best match** for this presentation with **brown-colored urine** (gross hematuria), **proteinuria**, **hypertension**, and **edema**. - Classically presents with **episodic gross hematuria** following upper respiratory tract infections. - The presence of **RBCs**, **granular casts**, and **acute nephritic features** (oliguria, facial puffiness, hypertension) are highly consistent with IgA nephropathy.
Question 4: What is the investigation of choice in a patient with blunt abdominal trauma with hematuria?
- A. USG of the abdomen
- B. Retrograde urogram
- C. IVP
- D. CECT (Correct Answer)
Explanation: ***Correct Answer: CECT*** - **Contrast-enhanced computed tomography (CECT)** is the investigation of choice for evaluating blunt abdominal trauma with hematuria as it accurately assesses the extent of injury to the **kidneys, ureters, bladder**, and surrounding structures. - It provides detailed images for detecting **renal lacerations, hematomas, urine extravasation**, and other abdominal organ injuries. - **Gold standard** in trauma protocols for comprehensive evaluation of renal and abdominal injuries. *Incorrect: USG of the abdomen* - **Ultrasound** can identify gross abnormalities like large hematomas or free fluid but is less sensitive than CECT for subtle renal injuries or collecting system disruptions. - It is often used as an initial screening tool (FAST exam) but not the definitive investigation of choice in this context. *Incorrect: Retrograde urogram* - A **retrograde urogram** primarily evaluates the **lower urinary tract** (ureters and bladder) by injecting contrast directly into the urethra. - It is not suitable for assessing the extent of renal parenchymal injury or other abdominal organ damage in blunt trauma. *Incorrect: IVP* - **Intravenous pyelogram (IVP)** uses intravenous contrast to visualize the kidneys, ureters, and bladder, but it has largely been replaced by CECT due to its lower sensitivity and specificity for traumatic injuries. - It provides less detailed anatomical information about surrounding soft tissues and can miss subtle parenchymal or vascular injuries.
Question 5: A 27-year-old woman presents with 26 weeks of gestation with a thyroid lesion which is found to be papillary carcinoma of thyroid. Which is the best treatment for this patient?
- A. Hemi-thyroidectomy
- B. Total thyroidectomy
- C. Thyroid ablation using radioactive Iodine
- D. Observation (Correct Answer)
Explanation: ***Observation*** - For **papillary thyroid carcinoma** diagnosed at **26 weeks of gestation**, **observation with close monitoring** is the best management approach. - At 26 weeks (late second trimester/approaching third trimester), the optimal surgical window (14-24 weeks) has passed, and surgery in the third trimester carries increased risk of preterm labor and maternal complications. - **Papillary thyroid carcinoma** has an **indolent course**, and delaying definitive treatment by 3-4 months until after delivery poses **minimal risk** to the mother. - **Close monitoring with ultrasound** should be performed, and **total thyroidectomy** should be planned for **after delivery**. - Surgery during pregnancy is only indicated for **rapidly growing tumors** or evidence of **aggressive features**, which are not mentioned in this case. *Total thyroidectomy* - While **total thyroidectomy** is the definitive treatment for papillary thyroid carcinoma, the **timing is critical** during pregnancy. - Surgery is ideally performed in the **second trimester (14-24 weeks)** to minimize risks to both mother and fetus. - At **26 weeks**, the patient is beyond the optimal surgical window, and performing surgery at this stage or in the third trimester increases the risk of **preterm labor** and other obstetric complications. - Definitive surgery should be **deferred until after delivery** unless there are aggressive features requiring urgent intervention. *Hemi-thyroidectomy* - **Hemi-thyroidectomy** is inadequate for papillary thyroid carcinoma and is only considered for very low-risk papillary microcarcinomas (<1 cm). - It does not provide adequate oncological control for diagnosed papillary carcinoma. *Thyroid ablation using radioactive Iodine* - **Radioactive iodine ablation** is absolutely **contraindicated during pregnancy** due to the risk of fetal thyroid destruction, leading to congenital hypothyroidism or cretinism. - While it is used as adjuvant therapy post-thyroidectomy in non-pregnant patients, it must be delayed until after delivery and cessation of breastfeeding.
Question 6: 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 7: What is the most common site for extramammary Paget's disease?
- A. Vulva (Correct Answer)
- B. Vagina
- C. Penis
- D. Anus
Explanation: **Explanation:** **Extramammary Paget’s Disease (EMPD)** is a rare intraepithelial adenocarcinoma that arises in skin areas rich in apocrine sweat glands. **Why Vulva is Correct:** The **vulva** is the most common site for EMPD, accounting for approximately **65% of all cases**. It typically presents in postmenopausal Caucasian women as a well-demarcated, erythematous, "eczematous-looking" plaque that may be itchy or burning. Histologically, it is characterized by the presence of **Paget cells** (large cells with clear, mucinous cytoplasm) within the epidermis. Unlike mammary Paget’s disease, which is almost always associated with an underlying breast malignancy, EMPD is associated with an underlying internal malignancy (like urogenital or colorectal cancer) in only about 20–30% of cases. **Why Other Options are Incorrect:** * **Vagina:** Primary Paget’s disease of the vagina is extremely rare; it usually occurs as a secondary extension from vulvar disease. * **Penis/Scrotum:** While the male genitalia are the second most common site for EMPD, they are significantly less frequently involved than the vulva. * **Anus:** Perianal Paget’s disease is the third most common site. It is clinically significant because it has a much higher association with underlying visceral (colorectal) malignancy compared to vulvar EMPD. **High-Yield Clinical Pearls for NEET-PG:** * **Staining:** Paget cells are **PAS positive**, **Alcian blue positive**, and **Mucicarmine positive** (indicating mucin production). * **Immunohistochemistry (IHC):** Typically **CK7 positive** and **CEA positive**. * **Differential Diagnosis:** Often misdiagnosed as chronic eczema, psoriasis, or fungal infection due to its "strawberries and cream" appearance. * **Management:** Wide local excision is the treatment of choice, though recurrence rates are high due to multifocal "skip" lesions.
Question 8: Regarding ectopia vesicae, which of the following is true EXCEPT?
- A. Carcinoma of the bladder may occur.
- B. There is a ventral curvature of the penis. (Correct Answer)
- C. There is incontinence of urine.
- D. There is visible uretero-vesical efflux.
Explanation: **Explanation** Ectopia vesicae (Bladder Exstrophy) is a complex congenital malformation resulting from a failure of the infra-umbilical anterior abdominal wall and bladder neck to fuse. **Why Option B is the correct answer (The Exception):** In ectopia vesicae, the penis is typically short and broad with a **dorsal curvature** (chordee), not a ventral one. This is because the urethral groove is open on the dorsal surface (Epispadias), and the corpora cavernosa are separated and shortened, pulling the penis upward toward the abdominal wall. Ventral curvature is characteristic of Hypospadias, not Exstrophy-Epispadias complex. **Analysis of other options:** * **Option A (True):** Chronic irritation and metaplasia of the exposed bladder mucosa significantly increase the risk of malignancy, most commonly **Adenocarcinoma** (due to glandular metaplasia), unlike the usual transitional cell carcinoma. * **Option C (True):** Since the bladder neck and sphincteric mechanisms are malformed and open, there is no reservoir function, leading to continuous **total incontinence**. * **Option D (True):** Because the posterior bladder wall (trigone) is exposed to the exterior, the ureteric orifices are visible, and one can directly observe the intermittent **efflux of urine** from them. **High-Yield Clinical Pearls for NEET-PG:** * **Associated skeletal finding:** Widening of the symphysis pubis (diastasis). * **Umbilicus:** Positioned lower than normal. * **Management:** Primary closure is ideally performed within 48–72 hours of birth. * **Most common malignancy:** Adenocarcinoma of the bladder. * **Key distinction:** Epispadias is always present in bladder exstrophy.
Question 9: What is the first-line treatment for overactive bladder?
- A. Antimuscarinic drug
- B. Behavioural therapy (Correct Answer)
- C. Cholinergic drug
- D. Botulinum toxin type A
Explanation: **Explanation:** **Overactive Bladder (OAB)** is a clinical syndrome characterized by urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence. **Why Behavioural Therapy is Correct:** According to the American Urological Association (AUA) and European Association of Urology (EAU) guidelines, **Behavioural Therapy is the first-line treatment** for OAB. It is non-invasive, has no systemic side effects, and is highly effective. It includes: * **Bladder training:** Scheduled voiding to increase bladder capacity. * **Pelvic floor muscle training (Kegel exercises):** To inhibit detrusor contractions. * **Lifestyle modifications:** Fluid management, caffeine reduction, and weight loss. **Analysis of Incorrect Options:** * **A. Antimuscarinic drugs (e.g., Oxybutynin, Tolterodine):** These are **second-line** treatments. They work by blocking M3 receptors on the detrusor muscle but are often limited by side effects like dry mouth, constipation, and blurred vision. * **C. Cholinergic drugs:** These (e.g., Bethanechol) stimulate bladder contraction and are used in urinary retention/hypotonic bladder, not OAB. OAB requires *anti*-cholinergics. * **D. Botulinum toxin type A:** This is a **third-line** treatment. It is reserved for patients refractory to behavioural and pharmacological therapies and is administered via intra-detrusor injection. **NEET-PG High-Yield Pearls:** * **Gold Standard Investigation:** Urodynamic study (shows detrusor overactivity). * **Mirabegron:** A $\beta_3$-adrenoceptor agonist, used as a second-line alternative to antimuscarinics (preferred in elderly to avoid cognitive side effects). * **Surgical Management:** Augmentation cystoplasty is the last resort for refractory cases.
Question 10: Subcapsular orchiectomy is done for cancer of which organ?
- A. Testes
- B. Prostate (Correct Answer)
- C. Penis
- D. Urethra
Explanation: **Explanation:** **Subcapsular orchiectomy** is a form of hormonal therapy used for the management of **advanced (metastatic) Prostate Cancer**. 1. **Why Prostate is correct:** Prostate cancer is an androgen-dependent malignancy. The primary goal of treatment in metastatic cases is **Androgen Deprivation Therapy (ADT)**. Since 95% of testosterone is produced by the Leydig cells in the testes, removing the testicular parenchyma achieves rapid surgical castration. In a "subcapsular" approach, the glandular tissue (testicular parenchyma) is removed while leaving the tunica albuginea and epididymis intact. This provides the same hormonal benefit as a total orchiectomy but offers a better cosmetic and psychological outcome for the patient. 2. **Why other options are incorrect:** * **Testes:** The standard surgery for testicular cancer is **Radical Inguinal Orchiectomy**. A subcapsular or trans-scrotal approach is strictly contraindicated as it risks scrotal seeding and alters lymphatic drainage. * **Penis & Urethra:** These malignancies are primarily managed via local excision, penectomy (partial/total), and lymph node dissection. They are not androgen-dependent, so orchiectomy plays no role in their standard management. **High-Yield Clinical Pearls for NEET-PG:** * **Hormonal Goal:** Orchiectomy aims to reduce serum testosterone to "castrate levels" (<50 ng/dL). * **Speed of Action:** Surgical castration is the fastest way to drop testosterone levels, making it ideal for patients with impending spinal cord compression (vertebral metastasis). * **LHRH Agonists vs. Orchiectomy:** While both are effective, LHRH agonists (e.g., Leuprolide) cause an initial "testosterone flare," whereas orchiectomy does not.
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free