Urology — MCQs

Urology Indian Medical PG Practice Questions and MCQs

Question 1041: 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.

Question 1042: In bladder injury, which of the following is the least likely site of referred pain?

A. Lower abdominal wall
B. Flank
C. Penis
D. Upper part of thigh (Correct Answer)

Explanation: ***Upper part of thigh*** - Pain from bladder injury is typically referred to areas innervated by the **S2-S4 spinal segments**, which supply the perineum, external genitalia, and posterior thigh. - The upper part of the thigh, particularly the anterior or medial aspects, is primarily innervated by the **lumbar plexus (L2-L4)**, making it a less common site for bladder pain referral. *Lower abdominal wall* - The bladder's superior surface peritoneum is innervated by **T11-L2 sympathetic fibers**, allowing for referred pain to the suprapubic and lower abdominal regions. - This is a common pattern for bladder distension or inflammation, as the peritoneum lining the bladder wall can stretch and trigger these fibers. *Flank* - While referred pain to the flank is more typical of **kidney or ureteral pathology**, severe bladder distension or irritation, especially if it irritates surrounding structures or peritoneum, can sometimes cause referred pain in this region. - The sensory innervation from the bladder can overlap with areas that refer to the flank, particularly through the **sympathetic pathways**. *Penis* - The penis receives sensory innervation from the **pudendal nerve (S2-S4)**, which shares spinal segments with the detrusor muscle of the bladder. - This common innervation pathway makes the penis a very likely site for referred pain from bladder injury or irritation, often described as a deep, radiating pain.

Question 1043: During TURP, the surgeon takes care to dissect above the verumontanum to avoid injury to

A. External urethral sphincter (Correct Answer)
B. Urethral crest
C. Prostatic utricle
D. Trigone of bladder

Explanation: ***External urethral sphincter*** - The **external urethral sphincter** is located just inferior to the verumontanum, meaning dissecting above the verumontanum helps preserve its function. - Injury to this sphincter is a major cause of **post-TURP incontinence**. *Urethral crest* - The **urethral crest** is a midline ridge on the posterior wall of the prostatic urethra, containing the verumontanum - Dissecting above the verumontanum would still be within the region of the urethral crest, not specifically to protect it. *Prostatic utricle* - The **prostatic utricle** is a small blind-ending pouch located within the verumontanum itself. - Dissecting above the verumontanum would not specifically prevent injury to the utricle, as it is integral to the verumontanum structure. *Trigone of bladder* - The **trigone of the bladder** is located superior to the prostatic urethra, forming the base of the bladder. - TURP primarily involves resection of prostatic tissue, and the trigone is not typically at risk if dissection is confined to the prostatic urethra.

Question 1044: Which of the following is NOT a suitable management option for accidental injury of the ureter during an abdominal operation?

A. Colonic implantation
B. End-to-end anastomosis through an ureteric catheter
C. Ligation of the ureter (Correct Answer)
D. Implantation into the bladder

Explanation: ***Ligation of the ureter*** - **Ligation** of the ureter is generally not a suitable management option as it typically leads to **kidney damage** due to obstruction and hydronephrosis, potentially necessitating **nephrectomy** if renal function is severely compromised. - This approach permanently blocks urine flow, causing **irreversible renal damage** unless the ureter is repaired or diverted very soon after injury. *End-to-end anastomosis through an ureteric catheter* - This is a common and appropriate technique for repairing a **transected ureter**, particularly when the injury is clean and there is minimal tissue loss. - An **ureteric catheter** acts as a stent, maintaining patency and facilitating healing while preventing stricture formation at the repair site. *Implantation into the bladder* - **Ureteroneocystostomy (implantation into the bladder)** is suitable for **distal ureteral injuries** where a sufficient length of ureter remains to reach the bladder without tension. - This procedure re-establishes continuity of the urinary tract directly into the bladder, bypassing the injured segment. *Colonic implantation* - **Colonic implantation** (ureterosigmoidostomy or ureterocolonic anastomosis) is a more complex procedure reserved for specific situations, such as extensive ureteral loss or bladder exstrophy, where direct bladder implantation is not feasible. - It involves diverting urine into the colon, allowing for reabsorption of water, but can lead to complications such as **hyperchloremic metabolic acidosis** and an increased risk of urinary tract infections.

Question 1045: Penile angiography is reliable only after intracavernosal injection of vasoactive substances. All are indications for penile angiography, EXCEPT:

A. Arteriovenous malformation
B. Painful priapism (Correct Answer)
C. Peyronie's disease
D. Erectile dysfunction

Explanation: ***Painful priapism*** - Penile angiography is generally **contraindicated** in painful priapism because the condition is an **emergency** requiring immediate intervention to restore blood flow and prevent irreversible cavernosal damage. - The goal in priapism is detumescence, not vascular mapping, and angiography could delay necessary treatment, potentially worsening outcomes. *Peyronie's disease* - Angiography can be used in select cases of Peyronie's disease to evaluate the **vascularity of plaques** or to identify associated vascular abnormalities that may contribute to erectile dysfunction alongside the curvature. - It helps in surgical planning, especially when considering **penile revascularization procedures** if vascular insufficiency is suspected. *Erectile dysfunction* - Penile angiography is a useful diagnostic tool for identifying the cause of certain types of **erectile dysfunction**, particularly those suspected to have a vascular origin like **arterial insufficiency** or **venous leak**. - It helps map the penile vasculature, providing precise anatomical information for potential **revascularization surgery** in carefully selected patients. *Arteriovenous malformation* - Angiography is the **gold standard** for diagnosing and characterizing **arteriovenous malformations (AVMs)** in the penis. - It provides detailed information on the feeding arteries and draining veins, which is crucial for planning **embolization** or **surgical resection** to treat the AVM.

Question 1046: What is the recommended treatment approach for disseminated seminoma?

A. Only RT
B. Only CT
C. Retroperitoneal lymph node dissection
D. CT and orchidectomy (Correct Answer)

Explanation: ***CT and orchidectomy*** - For disseminated seminoma, **chemotherapy (CT)** is the primary systemic treatment due to its high sensitivity to platinum-based regimens. - **Orchidectomy** (surgical removal of the testis) is crucial for both diagnosis and disease control, even in metastatic settings, to prevent local recurrence and provide tissue for definitive pathology. *Only RT* - **Radiotherapy (RT)** is effective for localized seminoma or adjuvant treatment of retroperitoneal disease, but it is insufficient as a standalone treatment for disseminated disease due to its limited reach. - While RT has a role in specific situations (e.g., residual masses post-chemotherapy), it cannot eradicate widespread metastatic seminoma on its own. *Only CT* - While chemotherapy is vital for disseminated seminoma, omitting **orchidectomy** would leave the primary tumor in situ, risking continued growth, bleeding, infection, and incomplete staging. - **Orchidectomy** provides definitive pathological diagnosis and removes the source of potential further spread, complementing the systemic effects of chemotherapy. *Retroperitoneal lymph node dissection* - **Retroperitoneal lymph node dissection (RPLND)** is a primary treatment modality for non-seminomatous germ cell tumors, particularly for persistent retroperitoneal disease after chemotherapy. - For seminoma, **chemotherapy** (and sometimes radiotherapy) is generally preferred for retroperitoneal involvement due to seminoma's high chemosensitivity, making RPLND less common and usually reserved for residual masses after chemotherapy.

Question 1047: Test to differentiate between psychological and organic erectile dysfunction is:

A. Pharmacologically induced penile erection therapy
B. Sildenafil induced erection
C. Squeeze technique
D. Nocturnal penile tumescence (Correct Answer)

Explanation: ***Nocturnal penile tumescence*** - **Nocturnal penile tumescence (NPT)** testing measures the occurrence and quality of **erections during sleep**. - Healthy men experience erections during REM sleep; their presence suggests a **psychological cause** for erectile dysfunction as the neural pathways for erection are intact. *Pharmacologically induced penile erection therapy* - This involves injecting **vasodilating agents** directly into the penis to induce an erection. - While it can confirm the capacity for erection, it does not differentiate between psychological and organic causes since both types of ED can respond to direct pharmacological intervention. *Sildenafil induced erection* - Sildenafil (Viagra) is a **PDE5 inhibitor** that works by enhancing the effects of nitric oxide during sexual stimulation. - An erection induced by sildenafil can occur in both psychological and organic ED as long as there is some capacity for vasodilation, thus it does not differentiate the underlying cause. *Squeeze technique* - The **squeeze technique** is a behavioral therapy used to treat **premature ejaculation**, not erectile dysfunction. - It involves stopping stimulation at the point of impending ejaculation and applying pressure to the penis to reduce arousal.

Question 1048: A patient presented with renal cell carcinoma invading the IVC and the renal vein. Which of the following statements is false?

A. Pre op radiotherapy is not essential
B. Chest x-ray should be done to rule out pulmonary metastasis.
C. Preop biopsy is not necessary
D. IVC involvement indicates inoperability (Correct Answer)

Explanation: ***Correct: IVC involvement indicates inoperability*** - This statement is **FALSE** and therefore the correct answer to this question - IVC involvement does NOT render RCC inoperable - Surgical resection with **radical nephrectomy and tumor thrombectomy** (cavotomy) can be performed successfully - **Even IVC tumor thrombus extending to the right atrium** can be surgically managed by experienced teams - Level of tumor thrombus determines surgical approach but not operability *Incorrect: Preop biopsy is not necessary* - This statement is **TRUE** (not the answer we're looking for) - Pre-operative biopsy typically not required when imaging is diagnostic for RCC - Cross-sectional imaging (CT/MRI) with characteristic features is usually sufficient - Biopsy risks include **tumor seeding** along the tract and potential for non-diagnostic sampling - Biopsy reserved for atypical presentations or when diagnosis unclear *Incorrect: Pre op radiotherapy is not essential* - This statement is **TRUE** (not the answer we're looking for) - RCC is **radioresistant** and responds poorly to radiation therapy - Pre-operative radiotherapy is NOT part of standard management for localized RCC - Surgery (radical nephrectomy) remains the primary curative treatment - Radiation may have palliative role in metastatic disease (bone mets, brain mets) *Incorrect: Chest x-ray should be done to rule out pulmonary metastasis* - This statement is **TRUE** (not the answer we're looking for) - **Lungs are the most common site** of RCC metastases - Chest imaging is essential component of pre-operative staging - **CT chest is preferred** over plain X-ray for better sensitivity in detecting pulmonary metastases - Complete staging includes CT chest, abdomen, and pelvis

Question 1049: Investigation of choice for vesico-vaginal fistula is:

A. X-ray
B. Cystoscopy (Correct Answer)
C. 3 Swab Test
D. IVP

Explanation: ***Cystoscopy*** - **Cystoscopy** is the **investigation of choice** (gold standard) for diagnosing vesicovaginal fistula as it allows **direct visualization** of the fistulous opening in the bladder wall. - It provides crucial information about the **size, location, and number** of fistulas, and the relationship to **ureteric orifices**, which is essential for **surgical planning**. - Combined with vaginoscopy, it offers comprehensive anatomical assessment and helps identify any associated bladder pathology. *3 Swab Test* - The **3-swab test** (dye test or tampon test) is a simple **bedside screening test** that helps **confirm** the presence of a vesicovaginal fistula. - Methylene blue is instilled into the bladder, and three tampons are placed in the vagina; staining of the top tampon confirms VVF, while staining of the lower tampons suggests ureterovaginal fistula. - While useful for **initial diagnosis and differentiation**, it does not provide anatomical details needed for surgical management. *IVP* - **Intravenous Pyelogram (IVP)** or CT urography is useful as a **complementary investigation** to assess upper urinary tract involvement and rule out **ureterovaginal fistula**. - It helps identify ureteric injuries or obstruction but is not the primary investigation for VVF diagnosis. *X-ray* - A plain **X-ray** has no role in diagnosing vesicovaginal fistula as it cannot visualize soft tissue fistulous tracts. - Contrast studies like **cystography** or **fistulography** may be used but are not the investigation of choice.

Question 1050: Which of the following statements about Peyronie's disease is false?

A. Surgical treatment is effective
B. It does not show a self-limited course.
C. Associated with fibrosis in the penis
D. It is not associated with Dupuytren's contracture. (Correct Answer)

Explanation: ***It is not associated with Dupuytren's contracture.*** - Peyronie's disease is, in fact, associated with other fibrotic conditions, including **Dupuytren's contracture** (fibrosis of the palmar fascia) and **Ledderhose's disease** (plantar fibromatosis). - This association suggests a common underlying genetic predisposition to fibrous tissue overgrowth. *Associated with fibrosis in the penis* - Peyronie's disease is characterized by the formation of **fibrous plaques** within the **tunica albuginea** of the penis. - This fibrosis leads to abnormal penile curvature, pain, and erectile dysfunction. *It does not show a self-limited course.* - While some cases might stabilize, Peyronie's disease typically has a **progressive course** or remains stable but problematic, often requiring intervention. - It is rarely self-limiting and often leads to worsening penile curvature and sexual dysfunction over time if left untreated. *Surgical treatment is effective* - **Surgical interventions**, such as plication, grafting, or incision/excision of plaques, are effective for severe penile curvature and improving erectile function in Peyronie's disease. - Surgery is typically reserved for patients with stable disease and significant erectile dysfunction or curvature that prevents intercourse.

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Renal Cell Carcinoma

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Testicular Tumors

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Urinary Incontinence

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