Urology — MCQs

Urology Indian Medical PG Practice Questions and MCQs

Question 201: A 50-year-old male presents with scrotal pain for 2 days. The pain decreases with elevation of the testis. What is the most likely clinical diagnosis?

A. Testicular torsion
B. Epididymoorchitis (Correct Answer)
C. Inguinal hernia
D. Hydrocele

Explanation: ### Explanation The clinical scenario describes a positive **Prehn’s sign**, which is a classic physical examination finding used to differentiate between causes of acute scrotum. **1. Why Epididymoorchitis is correct:** In **Epididymoorchitis**, inflammation of the epididymis and testis leads to congestion and gravity-dependent pain. When the scrotum is manually elevated, the physical support relieves the tension on the spermatic cord and suspensory structures, leading to a **decrease in pain (Positive Prehn’s sign)**. It typically presents in older men (or sexually active younger men) with a gradual onset of pain over 1–2 days, often accompanied by fever or urinary symptoms. **2. Why the other options are incorrect:** * **Testicular Torsion:** This is a surgical emergency. In torsion, elevation of the testis typically **increases the pain** (Negative Prehn’s sign) because the maneuver further twists the spermatic cord or aggravates the ischemia. The onset is usually sudden and occurs in a younger age group (adolescents). * **Inguinal Hernia:** While an incarcerated hernia can cause scrotal pain, it is usually associated with a cough impulse, intestinal symptoms (nausea/vomiting), and the inability to "get above the swelling." * **Hydrocele:** This is generally a painless, chronic swelling. While an infected hydrocele (pyocele) can be painful, it does not classically demonstrate a positive Prehn’s sign. **3. Clinical Pearls for NEET-PG:** * **Prehn’s Sign:** Positive (pain relief) = Epididymitis; Negative (no relief/increased pain) = Torsion. * **Cremasteric Reflex:** Usually **absent** in Testicular Torsion but **present** in Epididymoorchitis. * **Gold Standard Investigation:** Color Doppler Ultrasound (shows increased blood flow in epididymitis and decreased/absent flow in torsion). * **Age Factor:** Torsion is most common in the 12–18 age group; Epididymitis is more common in men >35 years.

Question 202: A 9-month-old boy presents with scrotal swelling. Physical examination reveals a scrotal mass that can be transilluminated and is composed of clear serous fluid. What is the most appropriate diagnosis?

A. Epididymitis
B. Hematocele
C. Hydrocele (Correct Answer)
D. Spermatocele

Explanation: **Explanation:** The clinical presentation of a painless scrotal swelling that **transilluminates** in an infant is a classic hallmark of a **Hydrocele**. **1. Why Hydrocele is correct:** A hydrocele is an accumulation of serous fluid within the tunica vaginalis. In infants, this is typically a **communicating hydrocele**, caused by the failure of the **processus vaginalis** to obliterate. The presence of clear serous fluid allows light to pass through the scrotum (positive transillumination test), which is the definitive physical finding to differentiate fluid-filled sacs from solid masses. **2. Why other options are incorrect:** * **Epididymitis:** This is an inflammatory condition characterized by severe pain, fever, and scrotal erythema. It would not present as a painless, transilluminating mass. * **Hematocele:** This is a collection of blood within the tunica vaginalis, usually following trauma or surgery. Because blood is opaque, a hematocele **does not transilluminate**. * **Spermatocele:** These are retention cysts of the epididymis containing spermatozoa. While they can transilluminate, they are exceptionally rare in infants and typically present as a distinct mass superior to the testis in post-pubertal males. **Clinical Pearls for NEET-PG:** * **Management:** Most congenital hydroceles resolve spontaneously by **1–2 years of age**. Surgical intervention (inguinal herniotomy) is indicated if it persists beyond age 2 or if an associated inguinal hernia is present. * **Anatomy:** The fluid in a hydrocele collects between the parietal and visceral layers of the **tunica vaginalis**. * **Differential:** Always perform the "get above the swelling" test; if you cannot get above it, suspect an **indirect inguinal hernia**.

Question 203: Displacement of a root into the maxillary sinus during extraction is most likely to happen during the extraction of which maxillary tooth?

A. Canine
B. Deciduous first molar
C. First molar (Correct Answer)
D. Second molar

Explanation: **Explanation:** The displacement of a root or a whole tooth into the maxillary sinus (Antrum of Highmore) is a known complication of dental extractions, primarily due to the close anatomical proximity between the root apices and the sinus floor. **Why the First Molar is Correct:** The **maxillary first molar** is the most common tooth involved because its roots (specifically the palatal and mesiobuccal roots) have the closest relationship to the floor of the maxillary sinus. In many individuals, only a thin layer of bone—or sometimes just the sinus mucosa—separates the root apices from the antrum. During extraction, apical pressure or improper use of elevators can easily force a fractured root tip through this thin barrier. **Analysis of Incorrect Options:** * **Canine:** The maxillary canine has a very long root, but it is situated anterior to the main body of the maxillary sinus. Its apex usually relates to the lateral wall of the nose rather than the sinus floor. * **Deciduous First Molar:** The roots of deciduous teeth are shorter and are separated from the sinus by the developing permanent premolar buds. The sinus is also less pneumatized in children. * **Second Molar:** While the second molar is also frequently in close contact with the sinus, statistically, the first molar is implicated more often due to its earlier eruption and higher frequency of extractions/pathology. **Clinical Pearls for NEET-PG:** * **Oro-Antral Communication (OAC):** This is the most common complication following the displacement of a root into the sinus. * **Radiology:** If a root is displaced, a **PNS (Para-nasal sinus) view** or OPG is required to locate it. * **Management:** Small, non-infected root tips (<2-3mm) may sometimes be left if there is no sinus disease; however, larger fragments usually require surgical retrieval via the **Caldwell-Luc approach**.

Question 204: Ureteric colic is characterized by all of the following EXCEPT:

A. Acute onset
B. Patients often prefer to remain still
C. Responds to antispasmodics (Correct Answer)
D. Pain radiates to the groin

Explanation: **Explanation:** Ureteric colic is a classic surgical emergency caused by the sudden obstruction of the ureter, usually by a calculus. **Why "Responds to antispasmodics" is the correct (incorrect statement) answer:** The primary mechanism of pain in ureteric colic is **prostaglandin-mediated** smooth muscle hyperperistalsis and mucosal edema. While the term "colic" suggests spasm, clinical evidence shows that **NSAIDs (like Diclofenac)** are the first-line treatment because they inhibit prostaglandin synthesis, reducing ureteric pressure and inflammation. Pure antispasmodics (like Hyoscine) are generally ineffective as monotherapy for the intense pain of an obstructing stone. **Analysis of other options:** * **Acute onset:** Ureteric colic typically presents as a sudden, excruciating pain that reaches peak intensity rapidly as the stone enters the narrow ureter. * **Patients prefer to remain still:** This is **false** regarding ureteric colic; patients are typically **restless** and "writhing in pain," constantly changing positions to find relief. This distinguishes it from peritonitis (e.g., perforated peptic ulcer), where patients prefer to lie perfectly still. *Note: In the context of this MCQ, Option B is a known characteristic of peritonitis, making it a potential distractor, but Option C is the standard "except" answer in surgical textbooks regarding pharmacological management.* * **Pain radiates to the groin:** This is a hallmark feature. As the stone moves down the ureter, pain radiates from the **loin to the groin** (T11-L2 distribution), often reaching the scrotum, labia, or inner thigh. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Non-contrast CT (NCCT) KUB. * **Narrowest site of the ureter:** Vesicoureteric junction (VUJ). * **Management:** NSAIDs are superior to opioids for pain relief; Medical Expulsive Therapy (MET) involves Alpha-blockers (Tamsulosin).

Question 205: What is the cause of hydrocele in infants?

A. Patent gubernaculum
B. Patent processus vaginalis (Correct Answer)
C. Cyst of Morgagni
D. Hormonal factors

Explanation: **Explanation:** The correct answer is **B. Patent processus vaginalis.** **Underlying Concept:** In fetal development, the testis descends from the abdomen into the scrotum preceded by a peritoneal fold called the **processus vaginalis**. Normally, the upper portion of this sac obliterates shortly before or after birth. If the processus remains **patent** (open), peritoneal fluid can track down into the scrotum, resulting in a **communicating hydrocele**. This is the most common cause of hydrocele in infants and children. If the opening is wide enough to allow abdominal contents (like bowel) to pass through, it is termed an indirect inguinal hernia. **Analysis of Incorrect Options:** * **A. Patent gubernaculum:** The gubernaculum is a mesenchymal structure that guides the descent of the testis; it does not form a sac or channel for fluid. * **C. Cyst of Morgagni:** Also known as the appendix testis, this is a vestigial remnant of the Müllerian duct. While its torsion can cause acute scrotal pain, it is not the cause of a generalized hydrocele. * **D. Hormonal factors:** While maternal hormones may cause transient neonatal breast enlargement or vaginal bleeding, they do not play a role in the anatomical patency of the processus vaginalis. **High-Yield Clinical Pearls for NEET-PG:** * **Management:** Most congenital hydroceles are managed conservatively as they often resolve spontaneously by **1–2 years of age** as the processus obliterates. * **Surgical Timing:** Surgery (Herniotomy) is indicated if the hydrocele persists beyond 2 years or if an associated inguinal hernia is present. * **Key Difference:** Unlike adult hydroceles (usually primary/idiopathic and treated with Lord’s procedure or Jaboulay’s eversion), pediatric hydroceles are almost always **communicating** and require **high ligation** of the patent processus vaginalis.

Question 206: What is the typical needle size (gauge) used for Fine Needle Aspiration Cytology (FNAC)?

A. 18-22
B. 22-26 (Correct Answer)
C. 27-29
D. 16-18

Explanation: **Explanation:** Fine Needle Aspiration Cytology (FNAC) is a diagnostic procedure used to investigate superficial lumps or masses. The goal is to obtain a cellular sample (cytology) rather than a tissue core (histology). **1. Why 22-26 Gauge is Correct:** The standard needle size for FNAC is **22 to 26 gauge**. This range is considered the "sweet spot" for cytology. A needle in this range is thin enough to minimize trauma and patient discomfort while providing enough capillary action to aspirate cells. Most importantly, it prevents significant blood contamination; if a needle is too wide, the sample becomes diluted with blood, making it difficult for the pathologist to visualize the cells (obscured morphology). **2. Analysis of Incorrect Options:** * **16-18 Gauge (Option D) & 18-22 Gauge (Option A):** These are "wide-bore" needles. They are typically used for **Core Needle Biopsy (CNB)**, where a solid piece of tissue architecture is required, or for fluid resuscitation and draining thick pus. Using these for FNAC leads to excessive bleeding and pain. * **27-29 Gauge (Option C):** These are ultra-fine needles (often used for insulin or local anesthesia). While they cause minimal pain, they are often too flexible to penetrate dense masses and have a lumen so narrow that they may fail to yield an adequate number of cells. **Clinical Pearls for NEET-PG:** * **FNAC vs. Biopsy:** FNAC provides *cytology* (individual cells); Core Biopsy provides *histology* (tissue architecture). * **Contraindication:** FNAC is generally avoided in suspected **Testicular Tumors** (due to the risk of scrotal seeding) and **Pheochromocytoma** (risk of a hypertensive crisis). * **Complication:** The most common complication of FNAC is a local hematoma. * **Suction vs. Non-suction:** For highly vascular organs (like the thyroid), the "non-aspiration" (Capillary) technique is often preferred to reduce blood contamination.

Question 207: What is the most common cause of water intoxication in a surgical patient?

A. Colorectal wash with plain water
B. Syndrome of inappropriate secretion of ADH
C. Irrigation during transurethral resection of the prostate
D. Excessive infusion of 5% glucose (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. Excessive infusion of 5% glucose.** **Why it is correct:** Water intoxication (dilutional hyponatremia) occurs when there is an excess of free water relative to sodium in the extracellular fluid. In a surgical setting, 5% Dextrose (glucose) is frequently used. Once infused, the glucose is rapidly metabolized by the body, leaving behind **free water**. If administered excessively or too rapidly, this free water shifts into the intracellular compartment via osmosis, leading to cellular edema, particularly in the brain, resulting in hyponatremic encephalopathy. This remains the most common iatrogenic cause of water intoxication in hospitalized surgical patients. **Analysis of Incorrect Options:** * **A. Colorectal wash with plain water:** While plain water is hypotonic and can be absorbed through the bowel mucosa, it is rarely performed in modern practice and is not the most common cause compared to IV fluid mismanagement. * **B. SIADH:** This is a common cause of hyponatremia post-surgery due to pain and stress; however, it is a pathological state of water retention rather than the most common exogenous cause of water intoxication. * **C. Irrigation during TURP:** This leads to **TURP Syndrome** due to the absorption of glycine or cytal. While it causes dilutional hyponatremia, it is specific only to patients undergoing transurethral prostatic surgery, making it less common globally than IV fluid errors. **High-Yield Clinical Pearls for NEET-PG:** * **TURP Syndrome:** Characterized by bradycardia, hypertension (initially), and CNS symptoms. It is caused by the absorption of large volumes of non-conductive irrigation fluid (e.g., 1.5% Glycine). * **Safe Fluid:** To prevent water intoxication, isotonic fluids like Normal Saline (0.9% NaCl) or Ringer’s Lactate are preferred for maintenance and resuscitation. * **Symptom Triad:** Early signs of water intoxication include headache, confusion, and muscle twitching, which can progress to seizures and coma.

Question 208: All of the following form radio-opaque stones except?

A. Calcium dihydrate
B. Cysteine
C. Struvite
D. Uric acid (Correct Answer)

Explanation: ### Explanation The radio-opacity of a urinary stone depends on its atomic weight and density. Stones containing calcium or heavy minerals attenuate X-rays, appearing white (radio-opaque), while those composed of organic compounds without heavy metals are radiolucent. **Why Uric Acid is the Correct Answer:** **Uric acid stones** are the classic example of **purely radiolucent** stones. They are formed in acidic urine and do not contain calcium or other high-atomic-number elements. On a plain X-ray (KUB), they are invisible. However, they can be visualized as filling defects on an IVP or clearly seen on a Non-Contrast CT (NCCT) scan. **Analysis of Incorrect Options:** * **Calcium dihydrate (Option A):** Calcium-containing stones (Oxalate/Phosphate) are the **most radio-opaque** stones due to the high atomic number of calcium. * **Cysteine (Option B):** These are described as **"ground-glass"** or **faintly radio-opaque**. While less dense than calcium, the sulfur atoms in cysteine provide enough density to be visible on X-rays. * **Struvite (Option C):** Also known as Triple Phosphate or Infection stones, these contain magnesium, ammonium, and calcium phosphate. They are radio-opaque and often form large **Staghorn calculi**. **High-Yield Clinical Pearls for NEET-PG:** * **Mnemonic for Radio-opacity (Decreasing order):** **C**alcium > **S**truvite > **C**ysteine > **U**ric acid/Xanthine (**C**an **S**omeone **C**lean **U**p?). * **Purely Radiolucent Stones:** Uric acid, Xanthine, and 2,8-Dihydroxyadenine. * **Indinavir Stones:** These are the only stones that are **radiolucent even on CT scans**. * **Gold Standard Investigation:** NCCT (Non-Contrast Computed Tomography) is the investigation of choice for all urinary stones as it detects both opaque and lucent stones.

Question 209: A 18-year-old male presents with pain and tenderness in the left scrotum, with a normal right scrotum. What is the most appropriate investigation?

A. B-mode ultrasound
B. Color Doppler ultrasound (Correct Answer)
C. CT scan
D. MRI

Explanation: **Explanation:** The clinical presentation of acute scrotal pain and tenderness in a young male is a surgical emergency, with **Testicular Torsion** being the most critical diagnosis to rule out. 1. **Why Color Doppler Ultrasound (CDUS) is the correct answer:** CDUS is the **investigation of choice** for acute scrotum. While B-mode ultrasound can show structural changes (like edema or whirlpool sign), it cannot assess blood flow. The hallmark of testicular torsion is the **absence or reduction of blood flow** to the affected testis. CDUS has high sensitivity (82-100%) and specificity (88-100%) for diagnosing torsion and differentiating it from inflammatory conditions like epididymo-orchitis (where blood flow is increased). 2. **Why other options are incorrect:** * **B-mode Ultrasound:** Useful for identifying anatomy, hydrocele, or tumors, but insufficient for assessing the vascular compromise essential for diagnosing torsion. * **CT Scan and MRI:** These are time-consuming, expensive, and not readily available in emergency settings. They play no role in the primary evaluation of an acute scrotum where "time is muscle." **Clinical Pearls for NEET-PG:** * **Golden Period:** Surgical detorsion should ideally occur within **6 hours** of symptom onset to ensure a nearly 100% salvage rate. * **Clinical Diagnosis:** If clinical suspicion of torsion is very high, surgical exploration should not be delayed for imaging. * **Prehn’s Sign:** Elevation of the scrotum relieves pain in epididymitis but **not** in torsion (Negative Prehn's sign). * **Cremasteric Reflex:** Typically absent in testicular torsion; its presence makes torsion less likely.

Question 210: A scrotal swelling is non-reducible but disappears on lying overnight and reappears slowly during the daytime. What is the diagnosis?

A. Congenital hydrocele (Correct Answer)
B. Varicocele
C. Indirect hernia
D. Sliding hernia

Explanation: ### Explanation The correct diagnosis is **Congenital Hydrocele**. #### 1. Why Congenital Hydrocele is Correct A congenital hydrocele occurs due to a **patent processus vaginalis (PPV)** that remains open but is too narrow to allow bowel or omentum to herniate. The communication is small, allowing peritoneal fluid to trickle down into the scrotum. * **The Mechanism:** During the day, gravity and increased intra-abdominal pressure cause fluid to accumulate in the scrotum. At night, while lying supine, the fluid slowly drains back into the peritoneal cavity. * **Clinical Sign:** This results in a swelling that is **non-reducible** (you cannot push it back manually like a hernia) but is **emptiable** (it disappears slowly over several hours of recumbency). #### 2. Why Other Options are Incorrect * **Indirect Hernia:** While it also involves a patent processus vaginalis, the opening is wide. Hernias are typically **reducible** (can be pushed back immediately) and cough impulse is present. They do not take "overnight" to disappear. * **Sliding Hernia:** This is a type of hernia where a retroperitoneal organ (like the cecum or bladder) forms part of the sac wall. It is usually large, partially reducible, and seen in elderly males, not typically following the "overnight disappearance" pattern. * **Varicocele:** This is a dilatation of the pampiniform plexus of veins ("bag of worms"). While it may diminish on lying down, it does not "disappear" in the same manner as a fluid-filled sac and is usually associated with a dragging pain. #### 3. NEET-PG High-Yield Pearls * **Gold Standard Investigation:** Scrotal Ultrasound (though diagnosis is primarily clinical). * **Transillumination Test:** Positive in hydrocele (brilliantly translucent), negative in hernia. * **Surgical Management:** The treatment for congenital hydrocele is **Herniotomy** (ligation of the PPV), not Lord’s or Jaboulay’s procedure (which are for primary/vaginal hydroceles). * **Key Distinction:** If the swelling is reducible = Hernia; if the swelling is emptiable = Congenital Hydrocele.

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