Urology — MCQs

Urology Indian Medical PG Practice Questions and MCQs

Question 371: Which of the following is NOT a feature of carcinoma of the penis?

A. Circumcision soon after birth provides total immunity.
B. Paget's disease is not a premalignant disease. (Correct Answer)
C. Metastasis to inguinal nodes.
D. Surgery is the treatment of choice.

Explanation: **Explanation:** Carcinoma of the penis is primarily a squamous cell carcinoma (SCC) associated with chronic irritation and HPV infection. **Why Option B is the correct answer:** Extramammary Paget’s disease of the penis is indeed a **premalignant condition**. It is an intraepithelial neoplasia (carcinoma-in-situ) that presents as a persistent, erythematous, velvety, or eczematous plaque. If left untreated, it can progress to invasive adenocarcinoma. Therefore, the statement "Paget's disease is not a premalignant disease" is false. **Analysis of other options:** * **Option A:** Neonatal circumcision provides near-total immunity against penile cancer by preventing phimosis and the accumulation of smegma (a known carcinogen). Note that circumcision later in life does not offer the same level of protection. * **Option C:** The primary route of spread for penile SCC is lymphatic. The **inguinal lymph nodes** (superficial and deep) are the first site of metastasis. The presence of nodal involvement is the most significant prognostic factor. * **Option D:** Surgery (ranging from wide local excision/glansectomy to partial or total penectomy) remains the **gold standard treatment** for the primary tumor. **High-Yield Clinical Pearls for NEET-PG:** * **Premalignant lesions:** Erythroplasia of Queyrat (glans/prepuce), Bowen’s disease (shaft), and Leukoplakia. * **Sentinel Node:** The **Cabanas node** (superomedial group of superficial inguinal nodes) is classically described as the first node involved. * **Risk Factors:** Phimosis (strongest association), HPV 16 and 18, smoking, and poor hygiene. * **Staging:** Uses the TNM system; inguinal lymphadenectomy is indicated if nodes remain palpable after 6 weeks of antibiotics or if the primary tumor is high-grade.

Question 372: Which of the following is NOT true about prostate-specific antigen (PSA)?

A. Normal levels are typically below 4 ng/mL. (Correct Answer)
B. Levels can be elevated in Benign Prostatic Hyperplasia (BPH) and prostate cancer.
C. It is produced by the prostate gland.
D. It is a glycoprotein.

Explanation: **Explanation:** The correct answer is **A** because the concept of a universal "normal" cutoff of 4 ng/mL is now considered outdated in modern urology. While 4 ng/mL was historically used as a threshold, PSA levels are **age-dependent**. As the prostate volume increases with age, the baseline PSA also rises. For example, the reference range for a man in his 40s is typically <2.5 ng/mL, whereas for a man in his 70s, it can be up to 6.5 ng/mL. Therefore, a single static value of 4 ng/mL is not universally "normal." **Analysis of other options:** * **Option B:** PSA is **organ-specific but not cancer-specific**. Levels rise in malignancy, but also in benign conditions like BPH, prostatitis, urinary tract infections, and even after physical trauma (e.g., catheterization or vigorous digital rectal exam). * **Option C:** PSA is a protease produced by the **ductal and acinar epithelium** of the prostate gland. Its physiological role is to liquefy the seminal coagulum. * **Option D:** Chemically, PSA is a **kallikrein-like serine protease** and is indeed a **glycoprotein**. **NEET-PG High-Yield Pearls:** * **PSA Velocity:** An increase of >0.75 ng/mL per year is highly suspicious for malignancy, even if the absolute value is <4 ng/mL. * **Free-to-Total PSA Ratio:** A ratio **<10-15%** suggests cancer, while a ratio **>25%** suggests BPH. * **PSA Density:** Calculated as PSA level divided by prostate volume (via TRUS); values **>0.15** increase the suspicion of cancer. * **Half-life:** PSA has a half-life of **2.2 to 3.2 days**. It takes about 2-3 weeks for levels to normalize after a rectal exam or biopsy.

Question 373: Circumcision is not indicated in which of the following conditions?

A. Paraphimosis
B. Balanoposthitis
C. Hypospadias (Correct Answer)
D. Carcinoma of the penis

Explanation: ### Explanation The correct answer is **Hypospadias**. **1. Why Hypospadias is the Correct Answer:** In hypospadias, the urethral meatus is located on the ventral aspect of the penis rather than at the tip of the glans. Circumcision is **strictly contraindicated** in these patients because the prepuce (foreskin) is essential for surgical repair. The vascularized skin of the prepuce is used as a flap or graft (e.g., Mathieu’s flap or Duckett’s procedure) to reconstruct the missing portion of the urethra (urethroplasty) and to provide skin coverage. Performing a circumcision would deprive the surgeon of this vital reconstructive material. **2. Why the Other Options are Wrong:** * **Paraphimosis (A):** This is a urological emergency where a retracted foreskin becomes trapped behind the glans, causing venous congestion. While the initial treatment is manual reduction, dorsal slit or formal circumcision is indicated to prevent recurrence. * **Balanoposthitis (B):** This refers to inflammation of the glans and the prepuce. Recurrent or chronic balanoposthitis (often seen in diabetics) is a common indication for circumcision to maintain local hygiene and prevent scarring/phimosis. * **Carcinoma of the Penis (D):** Circumcision is often performed as part of the management or biopsy process for penile cancer. Furthermore, neonatal circumcision is known to be a protective factor against the development of squamous cell carcinoma of the penis later in life. **Clinical Pearls for NEET-PG:** * **Absolute Contraindications to Circumcision:** Hypospadias, Epispadias, Chordee (without hypospadias), and Bleeding diathesis. * **Phimosis:** Physiological phimosis is normal up to age 3; pathological phimosis (e.g., BXO - Balanitis Xerotica Obliterans) is a definitive indication for circumcision. * **Complication:** The most common complication of circumcision is **hemorrhage**, followed by infection.

Question 374: Extrophy of the bladder is associated with which of the following conditions?

A. Congenital adrenal hyperplasia
B. Bifid clitoris (Correct Answer)
C. Rectal prolapse
D. Imperforate anus

Explanation: **Explanation:** **Bladder Exstrophy** is a complex congenital malformation resulting from the failure of the infra-umbilical mesenchymal tissue to migrate, leading to the breakdown of the cloacal membrane. This results in an exposed posterior bladder wall on the lower abdominal wall. **Why Bifid Clitoris is Correct:** In females with bladder exstrophy, the musculoskeletal defects of the pelvic girdle significantly impact the external genitalia. The pubic symphysis is widely diastased (separated), which pulls the lateral structures apart. Consequently, the **clitoris is bifid** (split into two halves), the labia are laterally displaced, and the vaginal orifice is often stenotic and anteriorly displaced. In males, this same mechanism results in **epispadias** and a short, broad penis. **Analysis of Incorrect Options:** * **A. Congenital Adrenal Hyperplasia (CAH):** This is an endocrine disorder causing virilization of female genitalia (clitoromegaly/fusion). It is not embryologically related to the mesenchymal migration defects seen in exstrophy. * **C. Rectal Prolapse:** While rectal prolapse *can* occur in children with exstrophy due to poor pelvic floor support (levator ani diastasis), it is a secondary complication rather than a primary anatomical association like the bifid clitoris. * **D. Imperforate Anus:** This is more characteristically associated with **Cloacal Exstrophy** (a more severe variant) rather than isolated Bladder Exstrophy. In classic bladder exstrophy, the anus is usually patent but may be anteriorly displaced. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Exposed bladder mucosa, epispadias, and wide symphysis pubis diastasis. * **Radiology:** "Mollusk-shell" appearance of the pelvis on X-ray due to pubic diastasis. * **Cancer Risk:** Patients have a significantly increased risk of **Adenocarcinoma** of the bladder (due to glandular metaplasia of the exposed mucosa). * **Umbilicus:** Always low-set in these patients.

Question 375: Ectopic testis is found in all locations except?

A. Lumbar
B. Perineal (Correct Answer)
C. Intra-abdominal
D. Inguinal

Explanation: ### Explanation The core concept in this question is the distinction between **Undescended Testis (Cryptorchidism)** and **Ectopic Testis**. **Understanding the Difference:** * **Undescended Testis:** The testis is arrested at some point along its **normal path of descent** (from the lumbar region to the scrotum). * **Ectopic Testis:** The testis has descended normally through the inguinal canal but has deviated from the normal path and is found in an **abnormal position** outside the path of descent. **Why the Options are Classified This Way:** * **Lumbar (A) and Intra-abdominal (C):** These are sites along the *normal* embryological path of descent. If a testis is found here, it is classified as **Undescended**, not ectopic. * **Inguinal (D):** The inguinal canal is the most common site for an **Undescended** testis. While an "interstitial" ectopic testis can exist near the inguinal canal, the term "Inguinal" primarily refers to the normal path. * **Perineal (B):** This is a classic site for an **Ectopic** testis. Other ectopic sites include the femoral canal, the base of the penis, and the superficial fascia of the thigh (Pre-scrotal). **Note on the Question Structure:** There appears to be a technical discrepancy in the provided key. In standard surgical teaching (Bailey & Love), **Perineal** is a classic site *for* an ectopic testis, whereas **Lumbar, Intra-abdominal, and Inguinal** are sites for *undescended* testes. If the question asks where an ectopic testis is **NOT** found, the answer should be one of the sites of the normal path (Lumbar/Abdominal/Inguinal). However, based on the provided key marking Perineal as "Correct," it suggests the question may be asking for the **most common site** of ectopia or is misphrased. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of Ectopic Testis:** Superficial Inguinal Pouch (Lockwood’s theory). * **Most common site of Undescended Testis:** Inguinal Canal. * **Complication Risk:** Both carry an increased risk of malignancy (Seminoma is most common), but the risk is higher in intra-abdominal testes. * **Management:** Orchidopexy is ideally performed between 6–12 months of age.

Question 376: What is the treatment of choice for a patient with stage III non-seminomatous testicular tumor?

A. Radiotherapy
B. Chemotherapy (Correct Answer)
C. Hormonal therapy
D. Surgery

Explanation: **Explanation:** The management of testicular tumors depends on the histological type (Seminoma vs. Non-Seminomatous Germ Cell Tumor - NSGCT) and the clinical stage. **Stage III NSGCT** indicates metastatic disease beyond the retroperitoneal nodes (e.g., supradiaphragmatic lymph nodes or visceral organs like the lungs). **Why Chemotherapy is the Treatment of Choice:** NSGCTs are highly chemosensitive but relatively radioresistant. For advanced stages (Stage IIB, IIC, and III), **platinum-based combination chemotherapy** is the gold standard. The standard regimen is **BEP (Bleomycin, Etoposide, and Cisplatin)**. Chemotherapy is used as the primary treatment to achieve systemic control of the disease. **Analysis of Incorrect Options:** * **Radiotherapy:** While Seminomas are exquisitely radiosensitive, **NSGCTs are radioresistant**. Radiotherapy has no role in the primary management of NSGCT. * **Surgery:** In Stage I NSGCT, Radical Orchidectomy followed by surveillance or Nerve-Sparing Retroperitoneal Lymph Node Dissection (RPLND) may be used. However, in Stage III, surgery is reserved for **residual masses** (>1 cm) that remain after the completion of chemotherapy. * **Hormonal Therapy:** This has no role in the management of germ cell tumors; it is primarily used in prostate cancer. **High-Yield Clinical Pearls for NEET-PG:** * **Tumor Markers:** NSGCTs often secrete **AFP** (Alpha-fetoprotein) and **beta-hCG**. Note: AFP is *never* elevated in pure seminomas. * **Most Common Site of Metastasis:** The first site of lymphatic spread is the **retroperitoneal lymph nodes** (Para-aortic). * **Post-Chemo Residual Mass:** If markers normalize but a mass >1cm remains in NSGCT, the next step is **RPLND** to rule out teratoma or viable tumor. * **Best Prognosis:** Seminoma; **Worst Prognosis:** Choriocarcinoma.

Question 377: Which of the following is a malignant germ cell tumor?

A. Embryonal teratoma
B. Dermoid cyst
C. Rhabdomyosarcoma
D. Seminoma (Correct Answer)

Explanation: **Explanation:** Testicular tumors are broadly classified into **Germ Cell Tumors (GCTs)**, which account for 95% of cases, and Sex Cord-Stromal Tumors. Germ cell tumors are further divided into **Seminomas** and **Non-Seminomatous Germ Cell Tumors (NSGCTs)**. **Why Seminoma is Correct:** Seminoma is the most common malignant germ cell tumor of the testis, typically occurring in the 4th decade of life. It is highly radiosensitive and carries an excellent prognosis. It arises from the germinal epithelium of the seminiferous tubules. **Analysis of Incorrect Options:** * **Embryonal teratoma:** While "Embryonal carcinoma" is a malignant GCT, the term "Embryonal teratoma" is often used synonymously with immature teratoma. In adults, all teratomas are considered potentially malignant, but "Seminoma" is the classic, definitive malignant GCT entity listed. * **Dermoid cyst:** This is a **benign** form of a mature cystic teratoma. In the ovary, it is the most common germ cell tumor and is benign, unlike its malignant counterparts. * **Rhabdomyosarcoma:** This is a malignant tumor of mesenchymal origin (skeletal muscle lineage), not a germ cell tumor. It is the most common soft tissue sarcoma in children. **High-Yield Clinical Pearls for NEET-PG:** * **Tumor Markers:** Seminomas may show elevated **hCG** (in 10-15% of cases) but **never** produce Alpha-Fetoprotein (AFP). If AFP is elevated, it is by definition an NSGCT (likely Yolk Sac component). * **Most Common:** Seminoma is the most common testicular tumor overall; however, **Yolk Sac Tumor** is the most common in infants/children. * **Risk Factor:** Cryptorchidism (undescended testis) is the most significant risk factor for developing a seminoma. * **Pathology:** Characterized by "large polyhedral cells with clear cytoplasm and distinct cell membranes" arranged in lobules separated by fibrous septa containing lymphocytes.

Question 378: Which lobe is most commonly involved in Benign Prostatic Hyperplasia (BPH)?

A. Lateral lobe
B. Median lobe (Correct Answer)
C. Anterior lobe
D. Posterior lobe

Explanation: **Explanation:** In Benign Prostatic Hyperplasia (BPH), the enlargement primarily involves the **Median lobe** and the **Lateral lobes**. However, the **Median lobe** is classically considered the most common and clinically significant site of enlargement leading to bladder outlet obstruction. * **Why Median Lobe is Correct:** Anatomically, BPH originates in the **Transition Zone** (McNeal’s classification). The median lobe (submucosal group of glands) sits directly beneath the bladder neck. When it enlarges, it projects into the bladder floor, creating a "ball-valve" effect and distorting the internal urethral orifice, making it the most common culprit for obstructive symptoms. * **Lateral Lobes:** These also frequently undergo hyperplasia in BPH. While they contribute significantly to urethral compression, the median lobe's strategic position at the bladder neck often makes its involvement more characteristic of the disease's pathology. * **Posterior Lobe:** This is the most common site for **Prostate Cancer** (originating in the Peripheral Zone). It is rarely involved in BPH. * **Anterior Lobe:** This area is largely fibromuscular and contains very little glandular tissue; it is almost never involved in hyperplastic or neoplastic processes. **High-Yield Clinical Pearls for NEET-PG:** * **Zonal Anatomy:** BPH = Transition Zone; Carcinoma = Peripheral Zone. * **Cystoscopy Finding:** An enlarged median lobe produces the "Intravesical Prostatic Protrusion" (IPP) seen on ultrasound or cystoscopy. * **J-shaped Ureter:** Significant median lobe enlargement can displace the ureters superiorly, leading to the "fish-hooking" or "J-shaped" appearance of the lower ureters on IVP. * **Rectal Examination:** BPH feels smooth, elastic, and rubbery, whereas carcinoma feels hard and nodular.

Question 379: A male patient sustained blunt trauma to the left side of the abdomen. How would you assess for kidney injury if the patient is hemodynamically stable?

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

Explanation: **Explanation:** In the management of blunt abdominal trauma, the gold standard for evaluating renal injuries in a **hemodynamically stable** patient is a **Contrast-Enhanced Computed Tomography (CECT) scan**. **Why CT Scan is the Correct Choice:** CECT is highly sensitive and specific. It allows for precise grading of renal injuries (AAST Grading I-V), identifies the presence and extent of retroperitoneal hematomas, and detects urinary extravasation. Most importantly, it assesses the functional status of both the injured and the contralateral kidney, which is vital for surgical planning. **Analysis of Incorrect Options:** * **Ultrasound (USG/FAST):** While useful for detecting free intraperitoneal fluid (hemoperitoneum), USG is poor at evaluating the retroperitoneum where the kidneys are located. It cannot reliably grade the injury or detect urinary leaks. * **X-ray:** Plain radiographs (KUB) are non-specific. They may show indirect signs like an absent psoas shadow or scoliosis, but they cannot diagnose the grade of renal trauma. * **MRI:** Although highly detailed, MRI is time-consuming, expensive, and impractical in an acute trauma setting. It is generally reserved for patients with iodine allergies or those who are pregnant. **High-Yield Clinical Pearls for NEET-PG:** * **Indications for Imaging in Renal Trauma:** 1. All blunt trauma with gross hematuria. 2. Blunt trauma with microscopic hematuria AND hypotension (SBP <90 mmHg). 3. All penetrating trauma with any degree of hematuria. * **Management Rule:** Most blunt renal injuries (Grades I-IV) in stable patients are managed **conservatively**. Absolute indications for surgery include hemodynamic instability or a Grade V shattered kidney with hilar avulsion. * **Pediatric Note:** Children are more prone to renal injury due to less perirenal fat and a less protected rib cage.

Question 380: What is the normal level of prostate-specific antigen (PSA) in males?

A. Less than 4 ng/ml (Correct Answer)
B. 4-10 ng/ml
C. Greater than 10 ng/ml
D. PSA is not produced by normal males

Explanation: **Explanation:** **1. Why Option A is Correct:** Prostate-Specific Antigen (PSA) is a glycoprotein enzyme secreted by the epithelial cells of the prostate gland. In a healthy male with a normal-sized prostate and no active pathology, the serum PSA level is typically **less than 4 ng/ml**. This value is widely accepted as the standard upper limit of normal for screening purposes. PSA functions physiologically to liquefy the semen coagulum after ejaculation. **2. Analysis of Incorrect Options:** * **Option B (4-10 ng/ml):** This range is known as the **"Gray Zone."** While not "normal," it is non-specific. Elevations in this range can be caused by Benign Prostatic Hyperplasia (BPH), prostatitis, or early-stage prostate cancer. The risk of malignancy in this zone is approximately 25%. * **Option C (>10 ng/ml):** This is a significantly elevated level. There is a high suspicion of prostate cancer (over 50% probability), and further diagnostic evaluation (like a TRUS-guided biopsy) is mandatory. * **Option D:** PSA is an organ-specific (though not cancer-specific) marker produced by all post-pubertal males. It is secreted by both normal and malignant prostatic tissue. **3. High-Yield Clinical Pearls for NEET-PG:** * **Age-Specific PSA:** Normal limits vary with age (e.g., <2.5 ng/ml for 40–49 years; <6.5 ng/ml for 70–79 years) due to increasing prostate volume. * **PSA Velocity:** An increase of **>0.75 ng/ml per year** is suspicious for malignancy, even if the total PSA is <4 ng/ml. * **Free-to-Total PSA Ratio:** A ratio **<10%** suggests cancer, while **>25%** suggests BPH. * **False Elevations:** PSA can be transiently elevated by Digital Rectal Examination (DRE), cystoscopy, prostatitis, urinary retention, or recent ejaculation. Always draw blood for PSA *before* performing a DRE.

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