Urology — MCQs

Urology Indian Medical PG Practice Questions and MCQs

Question 131: What is the most common cause of renal artery stenosis in individuals above 50 years of age?

A. Atherosclerosis (Correct Answer)
B. Fibromuscular dysplasia (FMD)
C. Takayasu arteritis
D. Renal cell carcinoma (RCC)

Explanation: **Explanation:** Renal Artery Stenosis (RAS) is a common cause of secondary hypertension. The etiology varies significantly based on the patient's age and gender. **1. Why Atherosclerosis is Correct:** Atherosclerosis is the most common cause of renal artery stenosis overall, accounting for approximately **90% of cases**. It typically affects individuals **above 50 years of age** and is often associated with other cardiovascular risk factors like smoking, diabetes, and hyperlipidemia. The lesion usually involves the **proximal third (ostium)** of the renal artery. **2. Analysis of Incorrect Options:** * **Fibromuscular Dysplasia (FMD):** This is the second most common cause but typically affects **younger females (20–40 years)**. It involves the distal two-thirds of the artery and presents with a characteristic "string of beads" appearance on angiography. * **Takayasu Arteritis:** A large-vessel vasculitis that can involve the renal artery ostium, but it primarily affects young Asian women and presents with systemic symptoms and absent pulses. * **Renal Cell Carcinoma (RCC):** While a tumor can compress the renal artery, it is a rare mechanical cause and not a primary vascular pathology for stenosis. **Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Digital Subtraction Angiography (DSA). * **Initial Screening Tool:** Duplex Doppler Ultrasound or CT Angiography. * **Classic Sign:** An abdominal bruit may be heard on auscultation. * **Treatment:** Medical management (ACE inhibitors/ARBs—*caution: contraindicated in bilateral RAS*), or Revascularization (Angioplasty with stenting) for atherosclerotic lesions.

Question 132: Which of the following statements regarding vasectomy is false?

A. Approximately 1 in 2000 men can become fertile again after the procedure.
B. Sperm granuloma is a common complication.
C. Sperm production is completely stopped following the procedure. (Correct Answer)
D. The procedure is typically performed under local anesthesia.

Explanation: ### Explanation **1. Why Option C is Correct (The False Statement):** Vasectomy is a procedure involving the occlusion or excision of a segment of the **vas deferens** to prevent sperm from entering the ejaculate. It is a method of contraception, not a method of suppressing spermatogenesis. **Sperm production in the testes continues** at a normal rate; however, since the exit path is blocked, the sperm are reabsorbed by macrophages in the epididymis. **2. Analysis of Incorrect Options:** * **Option A:** Recanalization (spontaneous re-joining of the cut ends of the vas) can occur, leading to failure. The incidence is approximately **1 in 2000**, making this a true statement. * **Option B:** **Sperm granuloma** is a common complication (occurring in up to 40% of cases pathologically). it occurs due to sperm leaking from the cut testicular end of the vas, triggering a chronic inflammatory response. * **Option D:** Vasectomy is a minor surgical procedure typically performed in an outpatient setting under **local anesthesia** (e.g., the "No-Scalpel Vasectomy" technique). **3. Clinical Pearls for NEET-PG:** * **Post-operative sterility:** Sterility is **NOT immediate**. Patients must use alternative contraception until **two consecutive semen analyses** (usually at 12 and 16 weeks) show azoospermia. * **Most common complication:** Hematoma and infection. * **Sperm Antibodies:** Following vasectomy, 60-80% of men develop anti-sperm antibodies, which can affect fertility success even after a surgical reversal (vasovasostomy). * **No Hormonal Change:** Vasectomy does not affect testosterone levels, libido, or erectile function.

Question 133: What is the column of Bertin in the kidney?

A. Renal tumour
B. Tongue-like papillary projection (Correct Answer)
C. Calculus
D. None

Explanation: ### Explanation **Concept Overview:** The **Columns of Bertin** (also known as renal columns) are extensions of the renal cortical tissue that project into the renal medulla, separating the renal pyramids. Anatomically, they represent the lateral portions of adjacent renal lobes. **Why Option B is Correct:** The columns of Bertin are characterized as **tongue-like papillary projections** of cortical tissue. They contain blood vessels and urinary tubes and are located between the renal pyramids. During development, they are formed by the fusion of the cortical caps of adjacent lobes. **Why Other Options are Incorrect:** * **Option A (Renal Tumour):** While a "Hypertrophied Column of Bertin" can sometimes mimic a renal mass on an ultrasound or CT scan (often called a **pseudotumor**), it is a normal anatomical variant, not a malignancy. * **Option C (Calculus):** A calculus is a solid piece of material (stone) formed from minerals in the urine. The Column of Bertin is soft tissue (parenchyma), not a calcification. **High-Yield Clinical Pearls for NEET-PG:** * **Pseudotumor:** A hypertrophied Column of Bertin is the most common cause of a "renal pseudotumor." It is typically found in the **middle third** of the kidney. * **Radiological Identification:** On a DMSA scan or contrast CT, a Column of Bertin shows the **same uptake/enhancement as the rest of the renal cortex**, which helps differentiate it from a true renal cell carcinoma (RCC). * **Location:** They are most frequently found on the left side and are often duplicated. * **Key Feature:** They do not distort the renal contour, unlike most true tumours.

Question 134: A 55-year-old diabetic patient presented with impotence and a history of failure to achieve erection after papaverine intracavernous injection. Color Doppler shows no abnormality of arteries but shows mild venous run-off. What is the treatment of choice?

A. Intracavernous injection of papaverine
B. Penile prosthetic implants
C. Vacuum constriction device (Correct Answer)
D. Psychotherapy

Explanation: **Explanation:** The patient presents with organic erectile dysfunction (ED) characterized by **venous leak** (mild venous run-off on Doppler) and a failure to respond to intracavernous pharmacotherapy (papaverine). **1. Why Option C is Correct:** In patients who fail pharmacological therapy (intracavernous injections) or have contraindications to them, the **Vacuum Constriction Device (VCD)** is a highly effective, non-invasive second-line treatment. It works by creating a negative pressure vacuum that draws blood into the corpora cavernosa, which is then maintained by a constriction ring at the base of the penis. It is particularly useful in diabetic patients and those with venous leak, as the ring prevents the premature venous outflow described in the question. **2. Why the other options are incorrect:** * **Option A (Papaverine):** The patient has already failed this treatment ("history of failure to achieve erection after papaverine"). Repeating it would be ineffective. * **Option B (Penile Prosthetic Implants):** This is the "gold standard" for refractory ED, but it is considered a **third-line** surgical intervention. One should attempt non-invasive second-line options like VCD before proceeding to irreversible surgery. * **Option D (Psychotherapy):** This is indicated for psychogenic ED. The presence of diabetes and the Doppler finding of venous run-off confirm an **organic** etiology. **Clinical Pearls for NEET-PG:** * **First-line treatment for ED:** Oral PDE-5 inhibitors (e.g., Sildenafil). * **Venogenic ED:** Characterized by normal arterial inflow but inability to maintain an erection due to "venous leak." * **Contraindication for VCD:** Patients with blood dyscrasias or those on anticoagulants (risk of priapism/hematoma). * **Papaverine:** A non-specific PDE inhibitor; its main side effect is priapism and corporal fibrosis.

Question 135: In a cystometrogram, where does LaPlace's law have its primary application?

A. Phase Ia (bladder volume less than 100 mL)
B. Phase Ib (bladder volume between 100-400 mL) (Correct Answer)
C. Phase II (bladder volume more than 450 mL)
D. All phases of the cystometrogram

Explanation: **Explanation:** In a cystometrogram (CMG), **Phase Ib** (the tonometric limb) represents the period of **accommodation**. During this phase, as the bladder fills (typically between 100–400 mL), there is a significant increase in volume with a very minimal increase in intravesical pressure. This phenomenon is governed by **LaPlace’s Law ($P = 2T/r$)**. As the bladder (a hollow sphere) fills, its radius ($r$) increases. According to LaPlace’s Law, for a constant wall tension ($T$), an increase in radius leads to a decrease in pressure ($P$). In a healthy bladder, the detrusor muscle relaxes and redistributes its fibers (viscoelastic properties) to maintain low pressure despite increasing volume. This allows the bladder to act as a low-pressure reservoir, which is critical for protecting the upper urinary tract. **Analysis of Incorrect Options:** * **Phase Ia:** This is the initial filling phase where there is a brief, sharp rise in pressure until the bladder's resting tone is established. It is too short-lived for the steady-state application of LaPlace’s law. * **Phase II:** This is the "limit of accommodation." Once the bladder reaches its functional capacity (usually >400-450 mL), the elastic limits are reached. Any further increase in volume causes a steep rise in pressure as the detrusor can no longer stretch; here, active myogenic properties override the passive laws of physics. * **Option D:** While physics applies throughout, the *primary* clinical application of LaPlace’s law is to explain the "flat" plateau of Phase Ib. **High-Yield Clinical Pearls for NEET-PG:** * **Compliance:** Calculated as $\Delta V / \Delta P$. Normal compliance is $>20-30 \text{ mL/cm } H_2O$. * **Law of LaPlace in Urology:** Explains why a large, chronically distended bladder (e.g., in chronic retention) may have lower pressure than a small, thick-walled spastic bladder. * **Normal Bladder Capacity:** First sensation of filling occurs at 150–250 mL; functional capacity is 300–500 mL.

Question 136: All are true regarding membranous urethral injury except?

A. It occurs due to a direct blow to the perineum. (Correct Answer)
B. High lying prostate is seen.
C. Pelvic hematoma occurs.
D. Urine collects in the perivesical space due to deep extravasation.

Explanation: **Explanation:** The membranous urethra is part of the **posterior urethra**. Injuries to this segment are almost exclusively associated with **pelvic fractures** (e.g., road traffic accidents), where the shearing force at the puboprostatic ligaments tears the urethra. **1. Why Option A is the Correct Answer (The False Statement):** A **direct blow to the perineum** (straddle injury) typically causes injury to the **bulbar urethra** (anterior urethra), not the membranous urethra. In straddle injuries, the bulbar urethra is crushed against the pubic symphysis. **2. Analysis of Other Options:** * **Option B (High-lying prostate):** When the membranous urethra is transected, the puboprostatic ligaments are torn, and the prostate is displaced superiorly by the developing pelvic hematoma. On Digital Rectal Examination (DRE), the prostate feels "boggy" or is non-palpable ("high-lying"). * **Option C (Pelvic hematoma):** Because the injury is above the urogenital diaphragm and associated with pelvic fractures, significant bleeding from the pelvic venous plexus leads to a large retroperitoneal/pelvic hematoma. * **Option D (Perivesical extravasation):** In posterior urethral injuries, the urogenital diaphragm remains intact. Therefore, urine and blood cannot reach the perineum or scrotum; instead, they collect in the **extraperitoneal perivesical space** (Retzius space). **Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Retrograde Urethrogram (RUG) is the investigation of choice for suspected urethral injury. * **Triad of Urethral Injury:** Blood at the external meatus, inability to void, and a palpable distended bladder. * **Management:** In acute posterior urethral injury, **Suprapubic Cystostomy (SPC)** is the initial management. Primary repair is generally avoided in the emergency setting. * **Key Distinction:** * *Posterior Urethra:* Pelvic fracture, high-lying prostate, perivesical extravasation. * *Anterior Urethra (Bulbar):* Straddle injury, butterfly hematoma in the perineum.

Question 137: Which of the following is NOT a radiolucent stone?

A. Triamterene stones
B. Uric acid stone
C. Xanthine stones
D. Cystine stones (Correct Answer)

Explanation: ### Explanation In urology, renal stones are classified based on their appearance on a plain X-ray (KUB). The visibility of a stone depends on its atomic weight and density. **1. Why Cystine stones are the correct answer:** Cystine stones are **radio-opaque** (visible on X-ray), though they appear less dense than calcium stones. They are often described as having a **"ground-glass"** or faint appearance. This is due to the presence of **sulfur atoms** within the cystine molecules, which have a higher atomic number, allowing them to attenuate X-rays. Therefore, they are NOT radiolucent. **2. Analysis of Incorrect Options (Radiolucent Stones):** * **Uric acid stones:** These are the most common radiolucent stones. They are composed of light elements (C, H, N, O) that do not stop X-rays. They are visible on CT scans or as filling defects on IVP. * **Xanthine stones:** Rare stones caused by genetic xanthine oxidase deficiency or Allopurinol therapy. Like uric acid, they lack heavy atoms and are radiolucent. * **Triamterene stones:** These are medication-induced stones. Triamterene (a potassium-sparing diuretic) is poorly soluble in urine and forms radiolucent calculi. **3. High-Yield Clinical Pearls for NEET-PG:** * **Mnemonic for Radiolucent stones (PURE):** **P**rotease inhibitors (Indinavir), **U**ric acid, **R**are (Xanthine/Matrix), **E**phedrine/Triamterene. * **Cystine Stones:** Associated with a hexagonal crystal shape in urine and a positive **Cyanide-Nitroprusside test**. * **Most Radio-opaque:** Calcium oxalate and Calcium phosphate (highest density). * **Intermediate/Faintly Opaque:** Cystine and Magnesium Ammonium Phosphate (Struvite). * **Gold Standard Investigation:** Non-contrast CT (NCCT) KUB detects almost all stones, including radiolucent ones (except Indinavir stones).

Question 138: Which of the following is the MOST common histological variant of prostate cancer?

A. Adenocarcinoma (Correct Answer)
B. Sarcoma
C. Seminoma
D. Squamous cell carcinoma

Explanation: **Explanation:** **Prostate cancer** is the most common malignancy in men globally. The correct answer is **Adenocarcinoma** because more than **95%** of all primary prostatic malignancies are histologically classified as acinar adenocarcinomas. These tumors typically arise from the **peripheral zone** of the prostate gland (70-80% of cases), which is why they are often detectable via Digital Rectal Examination (DRE). **Analysis of Options:** * **A. Adenocarcinoma (Correct):** As mentioned, acinar adenocarcinoma is the standard histological type. A less common subtype is ductal adenocarcinoma, which is more aggressive. * **B. Sarcoma:** Primary prostatic sarcomas (e.g., Rhabdomyosarcoma in children or Leiomyosarcoma in adults) are extremely rare, accounting for less than 0.1% of cases. * **C. Seminoma:** This is a germ cell tumor primarily found in the **testis**, not the prostate. While it can occur extragonadally (e.g., mediastinum), it is not a variant of prostate cancer. * **D. Squamous cell carcinoma:** This is an exceptionally rare variant (<0.5%) of prostate cancer, often associated with prior radiation therapy or hormonal treatment, and carries a very poor prognosis. **High-Yield Clinical Pearls for NEET-PG:** * **Gleason Scoring:** The grading system used for prognosis, based on architectural patterns (Score 2–10). * **Tumor Marker:** **PSA (Prostate Specific Antigen)** is the most important marker for screening and monitoring. * **Metastasis:** The most common site for distant metastasis is the **bone** (specifically the lumbar spine), typically presenting as **osteoblastic (sclerotic) lesions**. * **Spread:** Venous spread occurs via the **Baston’s vertebral venous plexus**, which explains the early spinal involvement without pulmonary involvement.

Question 139: Which of the following are indications for Transurethral Resection of the Prostate (TURP) in Benign Prostatic Hyperplasia (BHP)?

A. Prostatism, acute retention of urine, and haematuria
B. Acute retention of urine, haematuria, and complications like hydronephrosis
C. Prostatism, acute retention of urine, and complications like hydronephrosis
D. Prostatism, acute retention of urine, haematuria, and complications like hydronephrosis (Correct Answer)

Explanation: **Explanation:** The management of Benign Prostatic Hyperplasia (BPH) ranges from watchful waiting to surgical intervention. **Transurethral Resection of the Prostate (TURP)** remains the "gold standard" surgical treatment. The indications for surgery are generally categorized into severe bothersome symptoms and absolute complications arising from bladder outlet obstruction (BOO). **Why Option D is Correct:** This option encompasses the full spectrum of indications: 1. **Prostatism:** Refers to severe Lower Urinary Tract Symptoms (LUTS) that are refractory to medical management (Alpha-blockers/5-ARIs). 2. **Acute Urinary Retention (AUR):** Specifically when a patient fails at least one "Trial Without Catheter" (TWOC). 3. **Haematuria:** Recurrent or persistent gross haematuria secondary to friable prostatic congestion. 4. **Complications:** This includes **Hydronephrosis** (leading to post-renal azotemia/renal failure), recurrent Urinary Tract Infections (UTIs), and the formation of bladder stones. **Analysis of Incorrect Options:** * **Options A, B, and C** are partially correct but incomplete. In NEET-PG, when multiple correct clinical features are listed, the most comprehensive list is the superior choice. Option A misses upper tract changes; Option B misses symptomatic "prostatism"; Option C misses haematuria. **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Indications for Surgery:** Refractory urinary retention, recurrent UTIs, bladder calculi, persistent haematuria, and renal insufficiency due to BPH. * **TURP Syndrome:** Caused by the absorption of glycine (irrigating fluid), leading to dilutional hyponatremia and CNS toxicity. * **Size Limit:** Traditionally, TURP is preferred for prostates **<60-80 grams**. For larger glands (>80-100g), Open Prostatectomy or HoLEP (Holmium Laser Enucleation) is preferred. * **Most Common Complication:** Retrograde ejaculation (~75% of cases).

Question 140: What is the most common malignancy found in Marjolin's ulcer?

A. Basal cell carcinoma (BCC)
B. Squamous cell carcinoma (SCC) (Correct Answer)
C. Malignant fibrous histiocytoma
D. Malignant melanoma

Explanation: **Explanation:** A **Marjolin’s ulcer** refers to a malignancy arising in a site of chronic inflammation, long-standing scars, or non-healing wounds. The most common underlying cause is a **chronic burn scar** (cicatrix), though it can also occur in chronic osteomyelitis sinuses, venous stasis ulcers, and vaccination scars. **1. Why Squamous Cell Carcinoma (SCC) is correct:** The vast majority (approximately **75–90%**) of malignancies arising in Marjolin’s ulcers are **Squamous Cell Carcinomas**. The chronic irritation and repeated cycles of tissue damage and repair lead to cellular dysplasia and eventual malignant transformation into SCC. Notably, Marjolin’s SCC is typically more aggressive and has a higher rate of lymph node metastasis compared to SCC arising from sun-damaged skin. **2. Why other options are incorrect:** * **Basal Cell Carcinoma (BCC):** While BCC is the most common skin cancer overall, it is the second most common malignancy in Marjolin’s ulcers (approx. 10%). It is less frequent than SCC in this specific clinical context. * **Malignant Melanoma & Fibrous Histiocytoma:** These are extremely rare occurrences in chronic scars and do not represent the standard presentation of a Marjolin’s ulcer. **High-Yield Clinical Pearls for NEET-PG:** * **Latency Period:** The average time for malignant transformation is **30–35 years**. * **Characteristic Feature:** A Marjolin’s ulcer typically lacks the "everted edges" seen in standard SCC; instead, it presents as a persistent ulcer with indurated borders. * **Diagnosis:** Biopsy must be taken from the **edge/margin** of the ulcer. * **Treatment:** Wide local excision (usually with a 2 cm margin) or amputation, depending on the site and depth of invasion.

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Urological Anatomy

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Hematuria Evaluation

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Urinary Calculi

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Benign Prostatic Hyperplasia

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Prostate Cancer

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Bladder Cancer

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Renal Cell Carcinoma

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Testicular Tumors

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Urinary Tract Infections

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Urinary Incontinence

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Urology — MCQs

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