Urology — MCQs

Urology Indian Medical PG Practice Questions and MCQs

Question 1031: What is the first-line intervention for acute symptomatic hydroureter with ureteral obstruction requiring urgent decompression?

A. Antibiotic prophylaxis alone
B. Immediate ureterolithotomy
C. Endoscopic ureteral stenting (Correct Answer)
D. Urinary alkalization

Explanation: ***Endoscopic ureteral stenting*** - **Endoscopic ureteral stenting** is the primary intervention for **acute symptomatic ureteral obstruction** requiring urgent decompression when the obstruction causes **hydroureter**. - This minimally invasive procedure provides immediate drainage from the kidney to the bladder, preventing further renal damage, managing pain, and relieving obstruction. - **Indications for urgent stenting** include: infected hydronephrosis, impaired renal function, intractable pain, solitary kidney with obstruction, or bilateral obstruction. - Alternative to stenting is **percutaneous nephrostomy**, particularly when retrograde stent placement fails or in infected systems. *Antibiotic prophylaxis alone* - While antibiotics are essential when infection complicates obstruction (pyonephrosis), **antibiotics alone cannot relieve the mechanical obstruction**. - The physical blockage must be addressed to prevent progressive renal damage and sepsis. *Immediate ureterolithotomy* - **Open ureterolithotomy** is a definitive surgical treatment but is **not first-line** for acute obstruction. - It is more invasive and typically reserved for failed endoscopic management, large impacted stones, or anatomical abnormalities preventing endoscopic access. - Modern approach favors initial decompression followed by definitive treatment (ureteroscopy, ESWL, or surgery). *Urinary alkalization* - **Urinary alkalization** may help dissolve **uric acid stones** over time but does not provide immediate relief of acute obstruction. - This is an adjunctive measure for specific stone types, not an emergency intervention for symptomatic hydroureter.

Question 1032: Which condition is commonly associated with complications arising from phimosis?

A. Inability to retract the foreskin
B. Inflammation of the glans and foreskin (Correct Answer)
C. Urethral opening on the underside of the penis
D. Narrowing of the urethral opening

Explanation: ***Inflammation of the glans and foreskin*** - **Phimosis** (the inability to retract the foreskin) can lead to poor hygiene under the foreskin, creating an environment for bacterial or fungal growth. - This often results in **balanitis** (inflammation of the glans) or **balanoposthitis** (inflammation of both the glans and foreskin) due to retained secretions and microorganisms. *Inability to retract the foreskin* - This is the **definition** of phimosis, not a complication arising from it. - While it is the primary characteristic, it directly describes the condition itself rather than a subsequent problem. *Urethral opening on the underside of the penis* - This condition is known as **hypospadias**, a congenital anomaly of the urethra. - Hypospadias is a developmental issue and is unrelated to phimosis or its complications. *Narrowing of the urethral opening* - This condition is called **meatal stenosis** and refers to the narrowing of the external opening of the urethra. - While it can cause urinary symptoms, it is a distinct condition and not a direct complication of phimosis, although severe phimosis might indirectly impact urinary hygiene.

Question 1033: Most common site of urethral carcinoma in men is:

A. Prostatic urethra
B. Fossa navicularis
C. Penile urethra
D. Bulbomembranous urethra (Correct Answer)

Explanation: ***Bulbomembranous urethra*** - The **bulbomembranous (bulbar) urethra** is the **most common site** of primary urethral carcinoma in men, accounting for approximately **60% of cases**. - This region is lined by **pseudostratified columnar epithelium** and is often associated with **chronic irritation, strictures, or history of sexually transmitted infections**. - The most common histological type in this location is **squamous cell carcinoma**, followed by transitional cell carcinoma. *Penile urethra* - The **penile (anterior) urethra** is the second most common site, accounting for approximately **30% of urethral carcinomas**. - This region is lined by **stratified squamous epithelium**, making it susceptible to squamous cell carcinoma. - Often associated with **urethral strictures** or chronic inflammation. *Prostatic urethra* - The **prostatic urethra** is the **least common site** for primary urethral carcinoma, accounting for only about **10% of cases**. - Cancers in this region are more often **extensions from bladder cancer or prostate cancer** rather than primary urethral tumors. - When primary tumors occur here, they are typically **transitional cell carcinomas** (urothelial carcinomas). *Fossa navicularis* - The **fossa navicularis** is the distal-most portion of the **penile urethra**, not a separate anatomical site. - While it can be affected as part of penile urethral involvement, it is not considered separately in epidemiological data. - Tumors here are typically **well-differentiated squamous cell carcinomas**.

Question 1034: Chassar Moir operation is done in:

A. Rectovesical fistula
B. Urethrovaginal fistula
C. Vesicouterine fistula
D. Vesicovaginal fistula (Correct Answer)

Explanation: ***VVF*** - The **Chassar Moir operation** is a surgical procedure specifically designed for the repair of **vesicovaginal fistulae (VVF)**. - This procedure aims to close the abnormal communication between the **bladder** and the **vagina**, restoring urinary continence. *Vesicouterine fistula* - A vesicouterine fistula involves a communication between the **bladder** and the **uterus**, typically treated with different surgical approaches, often requiring a transcervical or transabdominal repair. - The Chassar Moir repair is primarily for **vesicovaginal defects**, not vesicouterine. *Urethrovaginal fistula* - A urethrovaginal fistula involves a defect between the **urethra** and the **vagina**, requiring specific surgical techniques to reconstruct the urethra. - The Chassar Moir operation does not directly address **urethral defects**. *Rectovesical fistula* - A rectovesical fistula is an abnormal connection between the **rectum** and the **bladder**, which is managed by colorectal and urological surgical teams, often requiring a transabdominal or transperineal repair. - This type of fistula is anatomically distinct from **vesicovaginal fistulae** and requires different surgical expertise.

Question 1035: Ectopic ureter may be frequently associated with which of the following conditions?

A. Dysuria
B. Paradoxical incontinence (Correct Answer)
C. Bilateral hydroureter
D. Oliguria

Explanation: ***Paradoxical incontinence*** - Ectopic ureters in females often insert distal to the external sphincter (e.g., vagina, vestibule), leading to **continuous leakage of urine** despite periods of normal voiding. This is known as paradoxical incontinence, where the bladder fills and empties normally, but urine also constantly dribbles from the ectopic opening. - In males, ectopic ureters usually insert proximal to the external sphincter (e.g., prostatic urethra, seminal vesicle) and therefore rarely cause incontinence but rather present with **ureteral obstruction** or **epididymitis**. *Oliguria* - **Oliguria** refers to a decreased urine output and is typically associated with **renal failure**, dehydration, or severe obstruction, not directly or frequently with an ectopic ureter itself. - An ectopic ureter may cause obstruction leading to **hydronephrosis** or renal damage, which could eventually lead to oliguria, but it is not the immediate or frequent direct association. *Dysuria* - **Dysuria** means painful urination, most commonly associated with **urinary tract infections (UTIs)**, urethritis, or bladder inflammation. - While an ectopic ureter can predispose to UTIs, dysuria is a symptom of infection rather than a direct, frequent consequence of the anatomical anomaly itself. *Bilateral hydroureter* - **Bilateral hydroureter** suggests obstruction of both ureters, often at the level of the bladder or urethra, or a systemic condition affecting both kidneys. - An ectopic ureter is usually a unilateral anomaly, causing **unilateral hydroureter** if it is obstructed, not typically bilateral.

Question 1036: What is a potential complication of performing percutaneous nephrolithotomy (PCNL) through the 11th intercostal space?

A. Pleural effusion (Correct Answer)
B. Hematuria
C. Colon injury
D. Residual stones

Explanation: ***Pleural effusion*** - Accessing the kidney through the **11th intercostal space** carries a higher risk of penetrating the **pleural cavity**, leading to **pleural injury** and subsequently a **pleural effusion** or pneumothorax. - This anatomical proximity means breaching the diaphragm which can result in leakage of fluid into the pleural space. *Hematuria* - **Hematuria** is a common and expected complication of PCNL due to direct trauma to the renal parenchyma and collecting system during the procedure. - While it can be significant (e.g., hemorrhage requiring transfusion), it is a direct consequence of kidney access and not uniquely linked to intercostal space entry. *Colon injury* - **Colon injury** is a risk of PCNL, but it is more commonly associated with an overly **medial or anterior trajectory** of the access tract, particularly in cases of bowel malrotation or mobile colon. - It is not specifically increased by using an 11th intercostal space approach, which is a posterior entry point. *Residual stones* - **Residual stones** are a potential outcome of any PCNL procedure if all stone fragments cannot be successfully removed during the initial surgery. - This complication relates to the efficacy of stone clearance and the complexity of the stone burden, not directly to the specific intercostal space chosen for access.

Question 1037: A 27-year-old man presents with a left testicular tumor and a 10 cm retroperitoneal lymph node mass. Which of the following is the treatment of choice?

A. Radiotherapy
B. Chemotherapy alone
C. Immunotherapy with interferon and interleukin
D. Radical inguinal orchiectomy plus chemotherapy (Correct Answer)

Explanation: ***Radical inguinal orchiectomy plus chemotherapy*** - For a suspected testicular tumor, the initial diagnostic and therapeutic step is a **radical inguinal orchiectomy** (high ligation of spermatic cord via inguinal approach) to avoid tumor seeding into the scrotum. - Given the presence of a 10 cm **retroperitoneal lymph node mass**, indicating bulky metastatic disease, **chemotherapy** (typically BEP regimen) is essential post-orchiectomy to address systemic spread. *Radiotherapy* - Radiotherapy may be used for specific stages of **seminoma**, but it is generally less effective for non-seminomatous germ cell tumors and is not the primary treatment for bulky metastatic disease (>5 cm). - It does not address the primary tumor in the testis directly and has higher long-term toxicities compared to chemotherapy for disseminated disease. *Chemotherapy alone* - While chemotherapy is crucial for metastatic testicular cancer, it cannot alone remove the primary tumor in the testis, which would leave a source of ongoing disease. - A **radical orchiectomy** is necessary to confirm the diagnosis, obtain tissue for histopathological staging, and remove the primary tumor. *Immunotherapy with interferon and interleukin* - **Immunotherapy** is generally not a first-line treatment for testicular germ cell tumors. - Standard treatment relies on platinum-based chemotherapy, which has excellent cure rates even in metastatic disease. Immunotherapy has limited role in testicular cancer management.

Question 1038: Which of the following statements about Varicocele is false?

A. Dilated pampiniform plexus veins
B. More common on right side (Correct Answer)
C. Doppler USG is best investigation
D. Abnormality increases on Valsalva

Explanation: ***More common on right side*** - Varicoceles are significantly **more common on the left side** due to anatomical differences, specifically the longer left testicular vein draining into the left renal vein at a perpendicular angle. - The perpendicular drainage and longer course of the left testicular vein create a higher pressure environment, predisposing to venous incompetence and dilation. *Dilated pampiniform plexus veins* - This statement is **true** because a varicocele is, by definition, an abnormal dilation and tortuosity of the veins of the **pampiniform plexus** within the spermatic cord. - The dilation occurs due to incompetent valves in the spermatic veins, leading to reflux of blood. *Doppler USG is best investigation* - This statement is **true** as **Doppler ultrasonography** is considered the gold standard for diagnosing varicoceles. - It allows visualization of dilated veins, demonstrates reflux with Valsalva maneuver, and helps grade the severity of the varicocele. *Abnormality increases on Valsalva* - This statement is **true** because the **Valsalva maneuver** increases intra-abdominal pressure, which impedes venous return and accentuates the reflux of blood into the testicular veins. - This maneuver helps to confirm the presence of a varicocele on physical examination and during Doppler ultrasonography.

Question 1039: In which of the following conditions is circumcision specifically indicated?

A. None of the above (not indicated)
B. Phimosis (when non-retractable) (Correct Answer)
C. Paraphimosis (as primary emergency treatment)
D. Balanitis (as first-line treatment)

Explanation: ***Phimosis (when non-retractable)*** - **Circumcision** is the definitive treatment for **pathological phimosis** where the foreskin cannot be retracted and causes symptoms like pain, dysuria, or recurrent infections. - This is a **primary and specific indication** for circumcision in both children (after conservative measures fail) and adults. - Phimosis can lead to complications like balanitis, urinary retention, and in severe cases, malignancy risk. *Paraphimosis (as primary emergency treatment)* - **Paraphimosis** is a urological emergency requiring **immediate manual reduction** or dorsal slit procedure to relieve strangulation of the glans. - **Circumcision is NOT the primary emergency treatment** - it is performed **electively later** to prevent recurrence after the acute episode is resolved. - The immediate priority is reduction of the paraphimosis, not circumcision. *Balanitis (as first-line treatment)* - **First-line treatment** for balanitis involves **topical antifungals, antibiotics, or corticosteroids** depending on the etiology. - **Circumcision** is indicated for **recurrent or refractory balanitis** after conservative measures have failed, not as initial first-line therapy. - It is a definitive preventive measure but not the primary treatment approach. *None of the above (not indicated)* - This is incorrect because **circumcision has clear medical indications** in urology and pediatric surgery. - Pathological phimosis is a well-established specific indication for the procedure.

Question 1040: A 60-year-old smoker presented with a history of a single episode of painless gross hematuria. The most logical investigation would be.

A. Urine cytology
B. X-ray of the kidneys, ureters, and bladder (KUB)
C. Cystoscopy (Correct Answer)
D. Ultrasound of the abdomen

Explanation: ***Cystoscopy*** - **Cystoscopy is the gold standard** and most essential investigation for evaluating **painless gross hematuria**, especially in high-risk patients (age >60, smoker). - It allows **direct visualization** of the bladder mucosa, urethra, and prostatic urethra, enabling detection of **bladder tumors** (the most common cause of painless hematuria in this demographic). - **Bladder cancer** presents classically with painless gross hematuria, and smoking is the strongest modifiable risk factor for urothelial carcinoma. - Current guidelines (AUA, EAU) recommend cystoscopy as a **mandatory component** of gross hematuria workup in adults, particularly with risk factors. - While it is invasive, it is the **most definitive initial investigation** and cannot be replaced by imaging alone. *Ultrasound of the abdomen* - Ultrasound is useful for evaluating the **upper urinary tract** (kidneys) and can detect masses or hydronephrosis. - However, it has **poor sensitivity for bladder lesions**, especially flat tumors like carcinoma in situ (CIS). - While ultrasound is part of the workup, it **cannot replace cystoscopy** in evaluating gross hematuria, as it may miss bladder pathology. - Best used as **complementary imaging** for upper tract evaluation rather than the primary investigation. *Urine cytology* - Urine cytology examines shed cells for malignancy and has **high specificity** but **variable sensitivity** (especially poor for low-grade tumors). - It is an **adjunct test** rather than a primary investigation and should not replace cystoscopy. - Most useful for detecting high-grade urothelial carcinoma and CIS, but cannot localize the lesion. *X-ray of the kidneys, ureters, and bladder (KUB)* - KUB primarily detects **radio-opaque calculi** and is not useful for soft tissue evaluation. - It has **no role** in evaluating painless hematuria when malignancy is suspected. - Stones typically cause **colicky pain**, not painless hematuria, making this investigation least appropriate in this scenario.

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Renal Cell Carcinoma

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Testicular Tumors

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Urinary Incontinence

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