Urology — MCQs

Urology Indian Medical PG Practice Questions and MCQs

Question 321: A 28-year-old male presents with lower abdominal pain associated with groin pain and nausea. Elevation of the testis relieves his pain. What is your diagnosis?

A. Ureteric colic
B. Prostatitis
C. Epididymo-orchitis (Correct Answer)
D. Torsion of testis

Explanation: ### Explanation The clinical presentation described is a classic case of **Epididymo-orchitis**. The hallmark finding here is the relief of pain upon elevation of the scrotum, known as a **Positive Prehn’s Sign**. **1. Why Epididymo-orchitis is correct:** In inflammatory conditions like epididymo-orchitis, elevating the testis reduces the gravitational pull on the inflamed structures and improves venous drainage, thereby relieving pain. In a 28-year-old male, this is most commonly caused by sexually transmitted infections (e.g., *Chlamydia trachomatis* or *Neisseria gonorrhoeae*). **2. Why other options are incorrect:** * **Torsion of Testis:** This is the most critical differential. However, in torsion, elevating the testis typically **exacerbates** the pain (Negative Prehn’s sign) because it further twists the spermatic cord. Torsion is a surgical emergency characterized by a sudden onset of pain and an absent cremasteric reflex. * **Ureteric Colic:** While it causes groin pain and nausea, it does not present with testicular tenderness or relief upon scrotal elevation. The pain typically radiates from "loin to groin." * **Prostatitis:** This usually presents with perineal pain, dysuria, and obstructive voiding symptoms rather than localized testicular pain relieved by elevation. **3. NEET-PG High-Yield Pearls:** * **Prehn’s Sign:** Positive (relief) in Epididymo-orchitis; Negative (no relief/worse) in Testicular Torsion. * **Cremasteric Reflex:** Preserved in Epididymo-orchitis; **Absent** in Testicular Torsion (most sensitive physical finding for torsion). * **Age Factor:** In patients <35 years, think STIs; in patients >35 years, think E. coli/UTI associated with BPH. * **Investigation of Choice:** Color Doppler Ultrasound (shows increased blood flow in orchitis, decreased/absent flow in torsion).

Question 322: A palpable plaque with a curved penis is indicative of which condition?

A. Condylomata
B. Peyronie disease (Correct Answer)
C. Penile cancer
D. Hypospadias

Explanation: **Explanation:** The clinical presentation of a **palpable plaque** associated with a **curved penis** (especially during erection) is the classic hallmark of **Peyronie’s Disease**. **1. Why Peyronie’s Disease is correct:** Peyronie’s disease is a connective tissue disorder involving the development of fibrous scar tissue (collagen plaques) within the **tunica albuginea** of the penis. Because this scarred area is inelastic, it does not expand during tumescence, causing the penis to bend toward the side of the plaque. It is often associated with painful erections and erectile dysfunction. **2. Why the other options are incorrect:** * **Condylomata (Genital Warts):** These are caused by HPV (Types 6 and 11) and present as soft, cauliflower-like fleshy growths on the skin or mucous membranes. They do not involve the tunica albuginea or cause penile curvature. * **Penile Cancer:** Typically presents as a painless, indurated ulcer or a fungating mass, usually on the glans or prepuce. While it involves a mass, it does not typically present as a discrete fibrous plaque causing curvature. * **Hypospadias:** This is a congenital anomaly where the urethral meatus is on the ventral aspect of the penis. While it can be associated with "chordee" (ventral curvature), it is present from birth and does not feature a palpable acquired plaque. **Clinical Pearls for NEET-PG:** * **Association:** Peyronie’s disease is strongly associated with **Dupuytren’s contracture** (palmar fascia fibrosis). * **Site:** The dorsal surface is the most common site for plaques, leading to upward curvature. * **Management:** Medical management includes Vitamin E, Potaba, or intralesional Collagenase (*Clostridium histolyticum*). Surgery (e.g., Nesbit procedure) is reserved for stable, severe cases interfering with intercourse.

Question 323: Circumcision is included in the management of carcinoma of the penis at which anatomical location?

A. Glans
B. Prepuce (Correct Answer)
C. Glanduloprepucial fold
D. Shaft of penis

Explanation: **Explanation:** The management of penile carcinoma is primarily determined by the anatomical location and the stage of the tumor. **Why Option B is Correct:** When a carcinoma is localized strictly to the **prepuce (foreskin)**, the standard surgical treatment is **radical circumcision**. This procedure ensures the complete removal of the primary lesion with adequate oncological margins while preserving the glans and the shaft of the penis. It is considered definitive treatment for Stage Tis, Ta, and T1a lesions, provided they are confined to the prepuce. **Why Other Options are Incorrect:** * **A. Glans:** Tumors of the glans usually require more extensive procedures such as glansectomy or partial penectomy to ensure clear margins, as circumcision does not remove the glans tissue. * **C. Glanduloprepucial fold:** Lesions involving the sulcus or the fold often involve both the glans and the prepuce. Simple circumcision is insufficient here; a partial penectomy is typically required to achieve a 1–2 cm margin. * **D. Shaft of penis:** Carcinoma of the shaft necessitates a partial or total penectomy depending on the depth of invasion and the ability to maintain a functional stump for micturition. **Clinical Pearls for NEET-PG:** * **Risk Factor:** Phimosis is the most significant risk factor for penile cancer (due to chronic inflammation/smegma). Neonatal circumcision is protective. * **Most Common Histology:** Squamous Cell Carcinoma (SCC) is the most common type (>95%). * **Lymph Node Spread:** Penile cancer spreads primarily via the lymphatics to the **Inguinal Lymph Nodes** (Sentinel node: Sentinel node of Cabanas). * **Surgical Margin:** Modern guidelines suggest that a **3–5 mm** surgical margin is often sufficient for low-grade lesions, though traditionally 1–2 cm was taught.

Question 324: Screening will significantly improve life span in which of the following conditions?

A. Carcinoma of the colon (Correct Answer)
B. Carcinoma of the prostate
C. Carcinoma of the lung
D. Carcinoma of the ovary

Explanation: ### Explanation The effectiveness of a screening program depends on the natural history of the disease, the availability of a sensitive test, and whether early intervention improves survival. **Why Carcinoma of the Colon is Correct:** Colorectal cancer (CRC) is the "gold standard" for screening success. It follows a predictable **adenoma-to-carcinoma sequence** that spans 10–15 years. Screening methods like **colonoscopy** are unique because they are both diagnostic and therapeutic; identifying and removing precancerous polyps (polypectomy) prevents the development of cancer entirely. Large-scale studies have conclusively shown that screening significantly reduces both the incidence and mortality of CRC, thereby increasing lifespan. **Why the Other Options are Incorrect:** * **Carcinoma of the Prostate:** While PSA (Prostate-Specific Antigen) testing is common, it is controversial. It often leads to **overdiagnosis** and overtreatment of indolent tumors that would never have caused death, without a definitive, significant increase in overall population lifespan. * **Carcinoma of the Lung:** Screening with Low-Dose CT (LDCT) is recommended only for high-risk smokers. However, for the general population, it has not shown a significant lifespan improvement due to high false-positive rates and the aggressive nature of the disease. * **Carcinoma of the Ovary:** There is currently **no effective screening tool** (including CA-125 and TVS) that has been proven to reduce mortality. Most cases are diagnosed at an advanced stage (Stage III/IV) despite screening attempts. **High-Yield Clinical Pearls for NEET-PG:** * **Best Screening Test for CRC:** Colonoscopy (every 10 years, starting at age 45 for average risk). * **Wilson and Jungner Criteria:** The classic criteria used to decide if a disease should be screened. * **Lead-time Bias:** The appearance of increased survival time just because the disease was detected earlier, not because the patient lived longer. * **Length Bias:** Screening tends to detect slowly progressing diseases rather than rapidly fatal ones.

Question 325: Which of the following procedures uses a trans-vesical approach in the surgical removal of prostate?

A. TURP
B. Millin prostatectomy
C. Freyer prostatectomy (Correct Answer)
D. Young's prostatectomy

Explanation: **Explanation:** The surgical management of Benign Prostatic Hyperplasia (BPH) involves different approaches depending on the size of the gland and the route taken to reach the prostate. **Why Freyer Prostatectomy is correct:** **Freyer’s procedure** is a **trans-vesical (suprapubic)** open prostatectomy. In this approach, the surgeon makes a midline subumbilical incision, opens the urinary bladder (cystotomy), and enucleates the adenoma through the bladder lumen. It is particularly indicated for very large prostates (>80-100g) or when there are associated bladder pathologies like large calculi or diverticula. **Analysis of Incorrect Options:** * **A. TURP (Transurethral Resection of the Prostate):** This is an endoscopic procedure where the prostate is reached via the **urethra**. It is the "Gold Standard" for moderate-sized glands but does not involve a trans-vesical incision. * **B. Millin Prostatectomy:** This is a **retropubic** open prostatectomy. The surgeon reaches the prostate through the space of Retzius without opening the bladder. The prostatic capsule is incised directly. * **C. Young’s Prostatectomy:** This uses a **perineal approach** to reach the prostate. It is rarely used for BPH today but was historically used for prostatic carcinoma. **High-Yield Clinical Pearls for NEET-PG:** * **Freyer’s:** Trans-vesical; main complication is primary/reactionary hemorrhage from the prostatic bed. * **Millin’s:** Retropubic; advantage is better visualization of the prostatic bed and no bladder injury, but it cannot address bladder stones. * **TURP Syndrome:** Caused by systemic absorption of glycine (irrigation fluid), leading to hyponatremia and neurological symptoms. * **Indication for Open Prostatectomy:** Generally reserved for prostate volume **>80-100 ml**.

Question 326: All of the following are features of carcinoma penis EXCEPT:

A. Surgery is the treatment of choice
B. Balanoposthitis may be a predisposing factor
C. Metastasizes to inguinal nodes
D. Histologically a transitional cell carcinoma (Correct Answer)

Explanation: **Explanation:** **Why Option D is the correct answer:** Carcinoma of the penis is histologically a **Squamous Cell Carcinoma (SCC)** in more than 95% of cases. It arises from the epithelium of the glans or the inner surface of the prepuce. **Transitional cell carcinoma (TCC)**, on the other hand, originates from the urothelium lining the urinary tract (renal pelvis, ureter, bladder, and proximal urethra) and is not the primary histology for penile cancer. **Analysis of other options:** * **Option A (Surgery is the treatment of choice):** Surgical resection (ranging from wide local excision or glans-preserving surgery to partial/total penectomy) remains the gold standard for managing the primary tumor. * **Option B (Balanoposthitis may be a predisposing factor):** Chronic inflammation, often due to **phimosis** and poor hygiene leading to **balanoposthitis** (inflammation of the glans and prepuce), is a major risk factor. The accumulation of smegma acts as a chronic irritant. * **Option C (Metastasizes to inguinal nodes):** The lymphatic drainage of the penis is primarily to the **inguinal lymph nodes** (superficial and deep). Nodal involvement is the most significant prognostic factor in penile cancer. **Clinical Pearls for NEET-PG:** * **Risk Factors:** HPV infection (Types 16 and 18), smoking, and lack of neonatal circumcision. * **Pre-malignant lesions:** Bowen’s disease (erythroplasia of Queyrat) and Leukoplakia. * **Staging:** Sentinel lymph node biopsy (SLNB) is indicated in intermediate/high-risk patients with clinically non-palpable nodes (cN0). * **Nodal Spread:** It follows a predictable pattern: Inguinal nodes → Iliac nodes → Distant metastasis. Skip lesions to iliac nodes are rare.

Question 327: Predisposing factors for carcinoma of the penis include all of the following except:

A. Paget's disease
B. Phimosis
C. Balanoposthitis
D. Papilloma (Correct Answer)

Explanation: **Explanation:** Carcinoma of the penis (most commonly Squamous Cell Carcinoma) is strongly associated with chronic irritation, poor hygiene, and specific viral infections. **Why Papilloma is the correct answer:** While Human Papillomavirus (HPV) types 16 and 18 are significant risk factors, a simple **Papilloma** (a benign epithelial tumor) is not considered a direct predisposing or premalignant condition for penile cancer. In contrast, conditions like *Erythroplasia of Queyrat* or *Bowen’s disease* (Carcinoma in situ) are the actual precursors. **Analysis of Incorrect Options:** * **Phimosis (Option B):** This is the most significant risk factor. It leads to the accumulation of **smegma**, which acts as a chronic chemical irritant and promotes bacterial decomposition, significantly increasing carcinogenic risk. * **Balanoposthitis (Option C):** Chronic inflammation of the glans and foreskin (often due to poor hygiene or phimosis) causes recurrent tissue injury and repair, which predisposes the epithelium to malignant transformation. * **Paget’s Disease (Option D):** Extramammary Paget’s disease of the penis is a rare intraepithelial neoplasia. It is considered a premalignant condition that can progress to or be associated with underlying adnexal carcinoma. **NEET-PG High-Yield Pearls:** * **Protective Factor:** Neonatal circumcision is highly protective against penile cancer (virtually eliminates the risk). * **Premalignant Lesions:** Remember the "Rule of B" – **B**owen’s disease (shaft), **B**alanitis Xerotica Obliterans (BXO), and **B**uschke-Löwenstein tumor (Giant Condyloma Acuminatum). * **Lymph Node Spread:** The first site of metastasis is usually the **Vertical group of Superficial Inguinal Lymph Nodes**. * **Sentinel Node:** The **Node of Cloquet** (deep inguinal) is a key landmark in surgical staging.

Question 328: What is the minimum daily nitrogen requirement for an adult with dynamic tissue turnover to maintain a positive nitrogen balance?

A. 3.5-4.5 g
B. 5.5-6.5 g (Correct Answer)
C. 7.5-8.5 g
D. 9.5-10.5 g

Explanation: **Explanation:** The nitrogen balance is a clinical measure of protein metabolism, calculated as the difference between nitrogen intake and nitrogen loss. In a healthy adult with dynamic tissue turnover, the goal is to maintain a **positive nitrogen balance** to support tissue repair and cellular function. **1. Why Option B is Correct:** The standard protein requirement for a healthy adult is approximately **0.8 to 1.0 g/kg/day**. Since protein contains roughly 16% nitrogen, 1 gram of nitrogen is equivalent to 6.25 grams of protein. For an average 70 kg adult, the daily protein requirement is ~70g. Dividing this by 6.25 yields approximately **11-12g of nitrogen** for total replacement. However, the **minimum** requirement to prevent a negative balance and sustain dynamic turnover in a resting state is lower, typically cited in surgical literature as **5.5 to 6.5 g of nitrogen per day**. **2. Analysis of Incorrect Options:** * **Option A (3.5-4.5 g):** This is insufficient for an average adult. Such low intake would lead to a negative nitrogen balance, resulting in muscle wasting and impaired wound healing. * **Options C & D (7.5-10.5 g):** While these values are closer to the "optimal" daily intake for an active individual or a patient in a mild hypermetabolic state, they exceed the "minimum" threshold required to maintain basic balance in a standard adult. **3. High-Yield Clinical Pearls for NEET-PG:** * **Nitrogen-to-Protein Ratio:** 1 g Nitrogen = 6.25 g Protein. * **Calorie-to-Nitrogen Ratio:** In parenteral nutrition, the ideal ratio for a stressed surgical patient is **100:1 to 150:1** (non-protein calories to grams of nitrogen). * **Negative Nitrogen Balance:** Common in burns, sepsis, and major trauma due to excessive catabolism. * **Urine Urea Nitrogen (UUN):** The most common method to measure nitrogen loss clinically.

Question 329: A 50-year-old man with a history of diabetes presents with a poor urinary stream, hesitancy, difficulty in micturition, and incomplete bladder emptying. What is the most likely diagnosis?

A. Benign prostatic hyperplasia (BPH)
B. Autonomic neuropathy (Correct Answer)
C. Urinary tract infection (UTI)
D. Atonic bladder

Explanation: ### Explanation The correct answer is **Autonomic Neuropathy**. **1. Why Autonomic Neuropathy is correct:** The key to this question lies in the patient's history of **Diabetes Mellitus**. Chronic hyperglycemia leads to peripheral and autonomic nerve damage. In the bladder, this manifests as **Diabetic Cystopathy**. Autonomic neuropathy affects the detrusor muscle's innervation, leading to decreased bladder sensation and impaired detrusor contractility. Patients typically present with a triad of decreased frequency of voiding, hesitancy, and a weak stream, ultimately leading to large residual volumes and incomplete emptying. **2. Why other options are incorrect:** * **Benign Prostatic Hyperplasia (BPH):** While BPH presents with similar obstructive symptoms in a 50-year-old male, the specific mention of "diabetes" in a medical exam context is a classic trigger for neuropathic complications. In BPH, the primary pathology is mechanical obstruction, whereas here it is functional (neurogenic). * **Urinary Tract Infection (UTI):** UTI typically presents with "irritative" symptoms like frequency, urgency, and dysuria, rather than the "obstructive" symptoms (poor stream, hesitancy) described here. * **Atonic Bladder:** This is the end-stage result of chronic denervation or overdistension. While autonomic neuropathy leads toward an atonic state, "Autonomic Neuropathy" is the specific underlying diagnosis/etiology linked to his diabetes. **3. NEET-PG High-Yield Pearls:** * **Diabetic Cystopathy:** Characterized by an insidious onset. The first sign is often an increased interval between voiding. * **Urodynamics:** In diabetic neuropathy, the cystometrogram (CMG) typically shows increased bladder capacity and a flat filling curve (impaired sensation). * **Management:** Timed voiding (voiding by the clock) and Crede’s maneuver (manual pressure) are initial steps; Bethanechol may be used, but clean intermittent catheterization (CIC) is often required for high residual volumes.

Question 330: What is the major hazard of an ectopic testis?

A. Impotence
B. Carcinoma
C. Liable to injury (Correct Answer)
D. Hernia

Explanation: ### Explanation The primary hazard of an **ectopic testis** is its increased susceptibility to **trauma (injury)**. Unlike an undescended testis (cryptorchidism), which is arrested along the normal path of descent (usually in the inguinal canal), an ectopic testis deviates from this path. It is most commonly found in the **superficial inguinal pouch** (Denis Browne pouch), but can also be perineal, femoral, or at the base of the penis. In these superficial and fixed locations, the testis lacks the protective mobility of the scrotum and is not shielded by the inguinal canal, making it highly **liable to injury** from external pressure or direct trauma. #### Analysis of Incorrect Options: * **A. Impotence:** Impotence (erectile dysfunction) is a vascular or neurological issue and is not caused by the malposition of a testis. * **B. Carcinoma:** While the risk of malignancy is significantly higher in an **undescended testis** (especially intra-abdominal), the risk in an ectopic testis is much lower because it resides in a cooler environment outside the abdominal cavity. * **D. Hernia:** An indirect inguinal hernia is almost always associated with an *undescended* testis due to a patent processus vaginalis. In ectopic testis, the processus vaginalis often closes normally, making hernia a less common association. #### High-Yield Clinical Pearls for NEET-PG: * **Most common site of ectopia:** Superficial inguinal pouch. * **Most common site of undescended testis:** Inguinal canal. * **Key Distinction:** An ectopic testis has a **long spermatic cord**, allowing it to be placed in the scrotum without tension (Orchidopexy), whereas an undescended testis has a **short cord**. * **Complications of Maldescended Testis:** Infertility (due to higher temperature), Malignancy (Seminoma is most common), Torsion, and Inguinal Hernia.

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