Urology — MCQs

Urology Indian Medical PG Practice Questions and MCQs

Question 221: Which of the following is used for the prevention of struvite stones?

A. Urine alkalinizer
B. Acetohydroxamic acid (Correct Answer)
C. Tiopronin
D. D-Penicillamine

Explanation: **Explanation:** **Struvite stones** (Magnesium Ammonium Phosphate) are also known as "infection stones" or "triple phosphate stones." They are caused by urea-splitting organisms like *Proteus*, *Klebsiella*, and *Pseudomonas*. These bacteria produce the enzyme **urease**, which hydrolyzes urea into ammonia and carbon dioxide, leading to highly alkaline urine (pH > 7.2) and stone formation. **Why Acetohydroxamic acid (AHA) is correct:** Acetohydroxamic acid is a potent, irreversible **urease inhibitor**. By inhibiting the bacterial enzyme, it prevents the breakdown of urea, thereby lowering urinary ammonia levels and preventing the alkalinization of urine. This halts the growth and formation of struvite stones. It is typically used as an adjunct to surgical removal (lithotripsy) in patients with chronic urea-splitting UTIs. **Why the other options are incorrect:** * **Urine alkalinizer (e.g., Potassium Citrate):** These are used for **Uric acid and Cystine stones**, which form in acidic urine. Since struvite stones thrive in alkaline environments, alkalinizers would worsen the condition. * **Tiopronin (α-mercaptopropionylglycine):** This is a second-generation chelating agent used specifically for the prevention of **Cystine stones** by increasing the solubility of cystine. * **D-Penicillamine:** This is a first-generation chelating agent also used for **Cystine stones**. It is less preferred than Tiopronin due to a higher side-effect profile (e.g., nephrotic syndrome, rashes). **NEET-PG High-Yield Pearls:** * **Struvite Stones:** Characteristically form **Staghorn calculi** (filling the renal pelvis and calyces). * **Radiology:** They are **radio-opaque** (though less dense than calcium oxalate). * **Microscopy:** Classic **"Coffin-lid"** appearance of crystals. * **Treatment Gold Standard:** Complete surgical removal (PCNL) is necessary because the stones harbor bacteria within their matrix, leading to recurrence if any fragment remains.

Question 222: Which of the following is a common presentation of genitourinary tuberculosis in a male patient?

A. Painful and tender epididymis
B. Bacteriuria without pyuria (Correct Answer)
C. Renal cysts (unilateral)
D. Microscopic hematuria

Explanation: **Explanation:** Genitourinary Tuberculosis (GUTB) is the second most common site of extrapulmonary tuberculosis. The hallmark clinical finding in GUTB is **Sterile Pyuria** (pus cells in the urine without growth on standard culture media). However, the classic presentation described in this context is **Bacteriuria without Pyuria** (or more accurately, the presence of *Mycobacterium tuberculosis* bacilli in the urine without a significant neutrophilic response in early or specific stages). *Note: While "Sterile Pyuria" is the most famous association, NEET-PG often tests the presence of the organism (bacteriuria) in the absence of common pyogenic bacteria.* **Analysis of Options:** * **Option B (Correct):** In GUTB, the urine is acidic. While pyuria is common, the "bacteriuria" refers to the shedding of tubercle bacilli. The absence of common pyogenic organisms on routine culture makes it a distinctive feature. * **Option A:** Incorrect. Tuberculous epididymitis typically presents as a **painless**, "beaded," or "knobby" enlargement of the epididymis, often associated with a thickened vas deferens. * **Option C:** Incorrect. GUTB leads to destructive lesions like "moth-eaten" calyces, infundibular strictures, and eventually a "putty kidney" (autonephrectomy), rather than simple unilateral cysts. * **Option D:** Incorrect. While hematuria can occur, it is usually a late feature. Sterile pyuria is a far more consistent and "common" diagnostic clue. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Culture on **Lowenstein-Jensen (LJ) medium** (takes 6–8 weeks). * **Earliest Radiological Sign:** Erosion of the tips of the papillae (moth-eaten appearance of calyces) on IVP. * **Thimble Bladder:** A small-capacity, fibrotic, contracted bladder resulting from chronic TB cystitis. * **Golf-hole Ureter:** A gaping, retracted ureteric orifice due to fibrosis.

Question 223: Which of the following statements about paraphimosis is true?

A. It can be induced by a urinary catheter.
B. Circumcision is a treatment for paraphimosis.
C. Hyaluronidase injection is a treatment for paraphimosis.
D. All of the above (Correct Answer)

Explanation: **Explanation:** **Paraphimosis** is a urological emergency where the prepuce (foreskin), once retracted behind the glans penis, cannot be reduced to its normal position. This leads to a tight constricting ring that impairs venous and lymphatic drainage, causing progressive edema of the glans and prepuce. **Why "All of the above" is correct:** * **Option A (Induced by urinary catheter):** This is a classic clinical scenario. During urethral catheterization, the foreskin is retracted to clean the glans. If the healthcare provider forgets to pull the foreskin back over the glans after the procedure, paraphimosis develops. * **Option B (Circumcision):** While manual reduction is the first-line treatment, **circumcision** (or a dorsal slit) is the definitive surgical treatment to prevent recurrence once the acute inflammation and edema have subsided. * **Option C (Hyaluronidase injection):** This is an adjunct medical management technique. Injecting hyaluronidase into the edematous prepuce breaks down hyaluronic acid, facilitating the rapid dispersion of extracellular fluid and making manual reduction easier. **High-Yield Clinical Pearls for NEET-PG:** 1. **Phimosis vs. Paraphimosis:** Phimosis is the inability to retract the foreskin; Paraphimosis is the inability to *reduce* a retracted foreskin. 2. **Emergency Status:** Paraphimosis is a surgical emergency because it can lead to arterial occlusion and **glans gangrene** if left untreated. 3. **Initial Management:** Manual compression of the glans (to reduce edema) followed by the **Dundee technique** (multiple needle punctures to drain fluid) or osmotic agents (granulated sugar/ice packs) are often tested. 4. **Definitive Management:** Dorsal slit (emergency) or Circumcision (elective/definitive).

Question 224: In which of the following diseases is overall survival increased by screening procedures?

A. Prostate cancer
B. Lung cancer
C. Colon cancer (Correct Answer)
D. Ovarian cancer

Explanation: **Explanation:** The primary goal of a screening program is to reduce disease-specific mortality and improve **overall survival (OS)**. Among the options provided, **Colon Cancer** is the only one where screening (via colonoscopy or fecal occult blood testing) has been definitively proven to increase overall survival. **1. Why Colon Cancer is Correct:** Screening for colorectal cancer (CRC) is unique because it allows for the detection and removal of **pre-malignant adenomatous polyps** (polypectomy). This prevents the progression to invasive carcinoma (primary prevention) and detects early-stage cancers that are highly curable (secondary prevention). Large-scale studies have shown that this significantly reduces both CRC-specific mortality and overall mortality. **2. Why Other Options are Incorrect:** * **Prostate Cancer:** While PSA screening increases the detection of early-stage disease, it leads to significant **overdiagnosis** of indolent tumors. Large trials (like PLCO) showed no significant improvement in overall survival, and the benefit in disease-specific mortality remains controversial due to the risks of overtreatment. * **Lung Cancer:** Low-dose CT (LDCT) screening reduces lung cancer-specific mortality in high-risk smokers, but its impact on *overall survival* in the general population is limited due to the high rate of false positives and complications from invasive follow-up. * **Ovarian Cancer:** Screening using CA-125 and transvaginal ultrasound (TVUS) has failed to show a reduction in mortality in major trials (UKCTOCS), as the disease is often detected too late or is biologically aggressive. **Clinical Pearls for NEET-PG:** * **Standard Screening Age (CRC):** Now recommended to start at **45 years** for average-risk individuals (previously 50). * **Gold Standard:** Colonoscopy every 10 years is the preferred screening modality. * **Wilson and Jungner Criteria:** These are the classic WHO criteria used to determine if a disease should be screened (e.g., recognizable latent stage, available treatment). * **Lead-time Bias:** A common pitfall in screening where survival *appears* longer because the disease was caught earlier, even if the date of death remains unchanged.

Question 225: Persistent urachus is a risk factor for which type of bladder cancer?

A. Transitional cell carcinoma of the bladder
B. Adenocarcinoma of the bladder (Correct Answer)
C. Squamous cell carcinoma of the bladder
D. Undifferentiated carcinoma of the bladder

Explanation: **Explanation:** The urachus is a fibrous remnant of the **allantois**, which normally obliterates to form the median umbilical ligament. It is lined by **glandular epithelium** (columnar epithelium). When the urachus fails to obliterate (persistent urachus), this glandular lining can undergo malignant transformation. Because the tissue of origin is glandular, the resulting malignancy is almost exclusively **Adenocarcinoma**. **Why the other options are incorrect:** * **Transitional Cell Carcinoma (TCC):** This is the most common type of bladder cancer overall (90%), arising from the urothelium. However, it is associated with smoking and aniline dyes, not urachal remnants. * **Squamous Cell Carcinoma (SCC):** This is typically associated with chronic irritation, such as **Schistosomiasis (Bilharziasis)** infection or long-term indwelling catheters/bladder stones. * **Undifferentiated Carcinoma:** This is a rare, aggressive form of bladder cancer that lacks specific histological features of the other types and is not specifically linked to urachal anomalies. **Clinical Pearls for NEET-PG:** * **Location:** Urachal adenocarcinoma typically occurs at the **dome of the bladder** (the most common site for this specific subtype). * **Classic Presentation:** A patient presenting with **mucusuria** (mucus in urine) and a midline mass between the umbilicus and the symphysis pubis. * **Rule of Thumb:** While TCC is the most common bladder cancer generally, **Adenocarcinoma** is the most common cancer found in a **persistent urachus** or **exstrophy of the bladder**. * **Management:** Requires radical cystectomy with en bloc resection of the urachal ligament and umbilicus.

Question 226: Sterile pyuria is characteristically seen in?

A. Renal Tuberculosis (Correct Answer)
B. Chronic Hydronephrosis
C. Wilm's Tumor
D. Neuroblastoma

Explanation: **Explanation:** **1. Why Renal Tuberculosis is the Correct Answer:** **Sterile pyuria** is defined as the presence of white blood cells (pus cells) in the urine (>5 WBCs/hpf) in the absence of growth on routine aerobic culture media. In **Renal Tuberculosis (Genitourinary TB)**, the *Mycobacterium tuberculosis* bacilli cause chronic inflammation and ulceration of the urothelium, leading to the shedding of WBCs. However, because *M. tuberculosis* does not grow on standard agar used for common pyogenic bacteria (like *E. coli*), the routine culture remains "sterile." This is a classic hallmark of GU-TB. **2. Why Other Options are Incorrect:** * **Chronic Hydronephrosis:** This is a structural dilatation of the renal pelvis and calyces. While it can predispose to infection, it does not characteristically present with sterile pyuria unless a specific secondary infection is present. * **Wilm’s Tumor (Nephroblastoma):** This is a pediatric renal malignancy. It typically presents as an asymptomatic abdominal mass or hematuria, not pyuria. * **Neuroblastoma:** This is an extra-renal tumor (usually arising from the adrenal medulla). It may displace the kidney but does not cause intrinsic pyuria. **3. Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** For Renal TB, the gold standard is a culture on **Lowenstein-Jensen (LJ) medium**, though automated liquid cultures (MGIT) are faster. * **Imaging:** Look for "moth-eaten" calyces on IVP (early sign) or a "Putty kidney" (autonephrectomy) in end-stage disease. * **Other causes of Sterile Pyuria:** Partially treated UTI, Urolithiasis, Chlamydia/Ureaplasma infections, and Interstitial Cystitis. * **Most common site:** The **epididymis** is the most common site of TB in the male reproductive tract, while the **kidney** is the most common site in the urinary tract.

Question 227: What is the best investigation to detect renal stones?

A. X-ray
B. CT scan (Correct Answer)
C. MRI
D. Ultrasound

Explanation: **Explanation:** The investigation of choice for detecting renal and ureteric stones is a **Non-Contrast Computed Tomography (NCCT) of the Kidney, Ureter, and Bladder (KUB)**. **Why CT Scan is the Correct Answer:** NCCT KUB is the gold standard due to its extremely high sensitivity (95-100%) and specificity. It can detect almost all types of stones, including **radiolucent stones** (like uric acid stones) that are invisible on X-rays. Furthermore, CT provides critical information for surgical planning, such as the stone's precise size, location, skin-to-stone distance, and **Hounsfield Units (HU)**, which indicate stone density/hardness. **Why Other Options are Incorrect:** * **X-ray (KUB):** It can only detect radiopaque stones (e.g., Calcium oxalate). It misses radiolucent stones and small stones obscured by bowel gas. Approximately 10-15% of urinary stones are radiolucent. * **Ultrasound (USG):** While it is the initial investigation of choice in pregnant women and children (to avoid radiation), it is operator-dependent and often misses small ureteric stones. It is excellent for detecting hydronephrosis but less sensitive for stone sizing. * **MRI:** Most urinary stones do not yield a signal on MRI, making them appear as signal voids. It is expensive, time-consuming, and significantly inferior to CT for stone detection. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard/Best Investigation:** NCCT KUB. * **Investigation of Choice in Pregnancy:** Ultrasound (1st line); MRI (2nd line if USG is inconclusive). * **Most Radiopaque Stone:** Calcium phosphate (Apatite). * **Purely Radiolucent Stones:** Uric acid, Xanthine, and Indinavir stones (Indinavir stones are the only ones not seen even on CT). * **Steinhagen Sign:** A CT finding where a "rim" of soft tissue edema surrounds a ureteric stone, helping differentiate it from a phlebolith.

Question 228: Which of the following substances forms radiopaque stones?

A. Xanthine
B. Oxalate (Correct Answer)
C. Uric acid
D. None of the above

Explanation: **Explanation:** The radiopacity of a urinary stone depends on its atomic weight and density. Calcium, having a high atomic number, is the primary element responsible for making stones visible on a plain X-ray (KUB). **1. Why Oxalate is Correct:** Calcium Oxalate (both monohydrate and dihydrate) is the most common type of urinary stone. Because it contains **calcium**, it is highly **radiopaque**. Calcium oxalate monohydrate stones are typically very hard and appear as dense shadows on radiographs. **2. Why Incorrect Options are Wrong:** * **Uric Acid:** These are the classic **radiolucent** stones. They are formed in acidic urine and do not contain heavy metals or calcium, making them invisible on plain X-rays (though they are visible on NCCT). * **Xanthine:** These are rare stones caused by a genetic deficiency of xanthine oxidase or the use of Allopurinol. Like uric acid, they are **radiolucent**. **3. NEET-PG High-Yield Pearls:** To master stone radiopacity, remember this hierarchy (from most opaque to least): * **Radiopaque:** Calcium Phosphate (most opaque) > Calcium Oxalate > Magnesium Ammonium Phosphate (Struvite/Triple Phosphate). * **Radiolucent (Pure):** **U**ric acid, **X**anthine, **I**ndinavir (HIV medication), and **M**atrix stones. (Mnemonic: **U**n-**X**-rayable **I**nvisibles). * **Semi-opaque/Ground Glass:** Cystine stones (due to sulfur content). **Clinical Note:** While uric acid stones are radiolucent on X-ray, **Non-Contrast CT (NCCT) KUB** is the gold standard investigation because it can detect almost all stones (except Indinavir stones).

Question 229: Orchiectomy is not indicated in which of the following conditions?

A. Seminoma testis
B. Prostatic carcinoma
C. Tubercular epididymitis (Correct Answer)
D. Male breast cancer

Explanation: **Explanation:** The correct answer is **Tubercular epididymitis** because it is a medical condition treated primarily with **Antitubercular Therapy (ATT)**. Surgery is reserved only for complications like cold abscesses or persistent sinuses. Orchiectomy is avoided because the goal is to preserve testicular function, as the infection usually starts in the epididymis and the testis is often involved only secondarily. **Analysis of Options:** * **Seminoma Testis:** High Inguinal Orchidectomy (HIO) is the gold standard treatment for all malignant testicular tumors. A trans-scrotal approach is contraindicated to prevent lymphatic spread to inguinal nodes. * **Prostatic Carcinoma:** Bilateral Orchidectomy (Therapeutic Castration) is a form of **Androgen Deprivation Therapy (ADT)**. It is indicated in metastatic prostate cancer to remove the primary source of testosterone, which fuels tumor growth. * **Male Breast Cancer:** Historically, bilateral orchidectomy was performed as palliative hormonal therapy to reduce estrogen/androgen levels, as male breast cancers are frequently hormone-receptor positive. **NEET-PG High-Yield Pearls:** 1. **High Inguinal Orchidectomy (HIO):** The incision is made at the internal inguinal ring; the spermatic cord is clamped first to prevent intraoperative seedling of tumor cells. 2. **TB Epididymitis:** Characterized by a "beaded" vas deferens and a "craggy" epididymis. It is the most common site of urogenital TB in males. 3. **Subcapsular Orchidectomy:** A variation used in prostate cancer where only the glandular tissue is removed, leaving the tunica albuginea for better cosmetic/psychological outcomes.

Question 230: A patient presents with a 'bag of worms' sensation in the scrotum. What is the most likely diagnosis?

A. Varicocele (Correct Answer)
B. Hydrocele
C. Torsion of testis
D. Congenital hernia

Explanation: **Explanation:** **Varicocele** is the correct diagnosis. It refers to the abnormal dilation and tortuosity of the pampiniform plexus of veins within the spermatic cord. The classic clinical description of a **"bag of worms"** sensation is due to these engorged, palpable veins. It is most commonly found on the **left side** (approx. 90%) due to the left testicular vein entering the left renal vein at a right angle, leading to increased hydrostatic pressure. **Why the other options are incorrect:** * **Hydrocele:** This is a collection of fluid within the tunica vaginalis. It presents as a smooth, fluctuant, non-tender swelling that **transilluminates** brightly, unlike the "worm-like" texture of a varicocele. * **Torsion of Testis:** This is a surgical emergency characterized by sudden, agonizing pain, a high-riding testis, and a negative Prehn’s sign. It does not present with a chronic "bag of worms" sensation. * **Congenital Hernia:** An indirect inguinal hernia presents as a swelling that may extend into the scrotum. It typically has an expansile cough impulse and is reducible, rather than feeling like a cluster of veins. **High-Yield Clinical Pearls for NEET-PG:** * **Infertility:** Varicocele is the most common reversible cause of male infertility (due to increased scrotal temperature and oxidative stress). * **Diagnosis:** Gold standard is **Color Doppler Ultrasound**. * **Grading:** Grade I (palpable only during Valsalva), Grade II (palpable while standing), Grade III (visible through scrotal skin). * **Red Flag:** A sudden onset, right-sided varicocele in an older man should raise suspicion of **Renal Cell Carcinoma (RCC)** obstructing the IVC.

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Renal Cell Carcinoma

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Testicular Tumors

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Urology — MCQs

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