Urology Practice Questions

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

Phimosis (when non-retractable). ***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.

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

Upper part of thigh. ***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.

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

External urethral sphincter. ***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.

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

Ligation of the ureter. ***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.

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

Painful priapism. ***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.

Q: What is the recommended treatment approach for disseminated seminoma?

CT and orchidectomy. ***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.

Q: Test to differentiate between psychological and organic erectile dysfunction is:

Nocturnal penile tumescence. ***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.

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

IVC involvement indicates inoperability. ***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

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

It is not associated with Dupuytren's contracture.. ***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.

Q: Investigation of choice for vesico-vaginal fistula is:

Cystoscopy. ***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 1

In which of the following conditions is circumcision specifically indicated?

Accepted Answer

Phimosis (when non-retractable)

Answer

None of the above (not indicated)

Answer

Paraphimosis (as primary emergency treatment)

Answer

Balanitis (as first-line treatment)

Question 2

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

Accepted Answer

Upper part of thigh

Answer

Lower abdominal wall

Answer

Flank

Answer

Penis

Question 3

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

Accepted Answer

External urethral sphincter

Answer

Urethral crest

Answer

Prostatic utricle

Answer

Trigone of bladder

Question 4

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

Accepted Answer

Ligation of the ureter

Answer

Colonic implantation

Answer

End-to-end anastomosis through an ureteric catheter

Answer

Implantation into the bladder

Question 5

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

Accepted Answer

Painful priapism

Answer

Arteriovenous malformation

Answer

Peyronie's disease

Answer

Erectile dysfunction

Question 6

What is the recommended treatment approach for disseminated seminoma?

Accepted Answer

CT and orchidectomy

Answer

Only RT

Answer

Only CT

Answer

Retroperitoneal lymph node dissection

Question 7

Test to differentiate between psychological and organic erectile dysfunction is:

Accepted Answer

Nocturnal penile tumescence

Answer

Pharmacologically induced penile erection therapy

Answer

Sildenafil induced erection

Answer

Squeeze technique

Question 8

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

Accepted Answer

IVC involvement indicates inoperability

Answer

Pre op radiotherapy is not essential

Answer

Chest x-ray should be done to rule out pulmonary metastasis.

Answer

Preop biopsy is not necessary

Question 9

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

Accepted Answer

It is not associated with Dupuytren's contracture.

Answer

Surgical treatment is effective

Answer

It does not show a self-limited course.

Answer

Associated with fibrosis in the penis

Question 10

Investigation of choice for vesico-vaginal fistula is:

Accepted Answer

Cystoscopy

Answer

X-ray

Answer

3 Swab Test

Answer

IVP

Urology — MCQs

Urology — MCQs

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