Urology — MCQs

Urology Indian Medical PG Practice Questions and MCQs

Question 431: A Gray-Hack shunt is used to treat priapism. Between which structures is this shunt placed?

A. Dorsal vein and corpus cavernosum
B. Corpus spongiosum and corpus cavernosum
C. Proximal penis between corpus cavernosum and saphenous vein (Correct Answer)
D. Corpus cavernosum and corpus spongiosum

Explanation: **Explanation:** Priapism is a urological emergency characterized by a persistent, painful erection lasting more than 4 hours. When conservative measures (aspiration and sympathomimetic injection) fail, surgical shunting is required to divert blood from the engorged **corpus cavernosum** to other venous systems. **1. Why Option C is Correct:** The **Gray-Hack shunt** is a **proximal cavernoso-venous shunt**. It involves creating an anastomosis between the **corpus cavernosum and the saphenous vein** (or sometimes the deep dorsal vein). By connecting the high-pressure cavernous tissue to the systemic venous circulation, it allows the trapped deoxygenated blood to drain, thereby achieving detumescence. **2. Analysis of Incorrect Options:** * **Option A:** While the dorsal vein can be used in some cavernoso-venous shunts, the specific eponym "Gray-Hack" refers to the saphenous vein bypass. * **Options B & D:** These describe **cavernoso-spongiosum shunts**. These are typically distal shunts (e.g., **Winter’s, Ebbehoj, or Al-Ghorab**) where a communication is created between the glans (which is part of the spongiosum) and the corpora cavernosa. **3. NEET-PG High-Yield Pearls:** * **Classification of Shunts:** * **Distal (Glandulo-cavernous):** Winter (percutaneous needle), Ebbehoj (scalpel), Al-Ghorab (open excision of tunica albuginea). * **Proximal (Cavernoso-spongiosum):** Quackels shunt. * **Proximal (Cavernoso-venous):** Gray-Hack (Saphenous vein). * **First-line Treatment:** Aspiration followed by intracavernosal injection of **Phenylephrine** (alpha-1 agonist). * **Ischemic vs. Non-ischemic:** Most surgical shunts are for **Ischemic (low-flow)** priapism, which is a compartment syndrome of the penis.

Question 432: Mark the true statement regarding carcinoma of the bladder?

A. Is primarily of squamous cell origin.
B. Is preferentially treated by radiation.
C. May be treated conservatively by use of intravesical agents even if it invades the bladder muscle.
D. May mimic an acute UTI with irritability and hematuria. (Correct Answer)

Explanation: **Explanation:** **Carcinoma of the bladder** most commonly presents as painless gross hematuria. However, in about 20% of cases, it presents with **irritative voiding symptoms** such as frequency, urgency, and dysuria (mimicking a UTI). This is particularly common in **Carcinoma in Situ (CIS)** or infiltrating tumors, where the bladder wall's integrity is compromised, leading to irritability and hematuria. **Analysis of Options:** * **Option A (Incorrect):** Globally and in India, the most common histological type is **Urothelial (Transitional Cell) Carcinoma** (>90%). Squamous cell carcinoma is less common and usually associated with chronic irritation (e.g., Schistosomiasis or long-term catheters). * **Option B (Incorrect):** The gold standard for Muscle-Invasive Bladder Cancer (MIBC) is **Radical Cystectomy**. Radiation is typically reserved for bladder preservation protocols or palliative care in patients unfit for surgery. * **Option C (Incorrect):** Intravesical agents (like BCG or Mitomycin C) are indicated only for **Non-Muscle Invasive Bladder Cancer (NMIBC)**. Once the tumor invades the detrusor muscle (T2 stage), conservative management is contraindicated due to the high risk of metastasis. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Smoking (most significant), occupational exposure to aromatic amines (Aniline dyes), and Cyclophosphamide. * **Diagnosis:** Gold standard is **Cystoscopy with biopsy**. * **Staging:** The presence of **detrusor muscle** in the biopsy specimen is crucial to differentiate between NMIBC and MIBC. * **Schistosomiasis:** Specifically linked to Squamous Cell Carcinoma of the bladder.

Question 433: All of the following are seen in interstitial cystitis except:

A. Fever (Correct Answer)
B. Hematuria
C. Dysuria
D. Presence of linear bleeding ulcer in the fundus

Explanation: **Explanation:** Interstitial Cystitis (IC), also known as **Bladder Pain Syndrome**, is a chronic inflammatory condition of the bladder wall of unknown etiology. It primarily affects middle-aged women and is characterized by a triad of urinary frequency, urgency, and pelvic pain that is relieved by voiding. **Why Fever is the correct answer:** Interstitial cystitis is a **non-infectious** inflammatory condition. Unlike bacterial cystitis or pyelonephritis, IC does not typically present with systemic signs of infection such as fever, chills, or leukocytosis. The presence of fever should prompt a search for an alternative diagnosis, such as an active urinary tract infection (UTI) or malignancy. **Analysis of other options:** * **Hematuria:** Chronic inflammation and the presence of mucosal fissures or ulcers can lead to both microscopic and, occasionally, gross hematuria. * **Dysuria:** Patients frequently experience painful urination and significant suprapubic pain as the bladder fills. * **Linear bleeding ulcers (Hunner’s Ulcers):** This is a classic diagnostic finding seen on cystoscopy (usually under overdistension). These are not true ulcers but rather patches of red, mucosal inflammation with small vessels radiating out, which may bleed or crack (linear scars) upon bladder distension. They are typically found in the body or fundus of the bladder. **Clinical Pearls for NEET-PG:** * **Demographics:** Female to Male ratio is approximately 10:1. * **Cystoscopy Findings:** Look for **Hunner’s ulcers** (pathognomonic but seen in only 10-20%) and **Glomerulations** (pinpoint petechial hemorrhages after hydrodistension). * **Biopsy:** Characteristically shows an increased number of **Mast cells** in the detrusor muscle. * **Treatment:** First-line includes lifestyle changes; Pharmacotherapy includes **Pentosan Polysulfate Sodium** (the only FDA-approved oral drug) and Amitriptyline.

Question 434: According to the Weige Meyer rule of ureteral duplication, the lower pole ureter in the urinary bladder is:

A. Lateral and cephalad to the upper pole ureter (Correct Answer)
B. Lateral and caudal to the upper pole ureter
C. Medial and cephalad to the upper pole ureter
D. Medial and caudal to the upper pole ureter

Explanation: The **Weigert-Meyer Rule** is a fundamental principle in pediatric urology describing the anatomical relationship of duplicated ureters. In a complete ureteral duplication, the two ureters cross each other as they descend toward the bladder. ### **Mechanism of the Rule** The rule states that the ureter draining the **upper pole** of the kidney inserts into the bladder **medially and caudally** (lower) than the lower pole ureter. Conversely, the ureter draining the **lower pole** inserts **laterally and cephalad** (higher). 1. **Why Option A is Correct:** During embryological development, the lower pole ureteric bud incorporates into the bladder wall first. As the bladder grows and the trigone expands, this orifice is pulled **laterally and superiorly (cephalad)**. 2. **Why Options B, C, and D are Incorrect:** These options reverse the spatial orientation. The upper pole ureter is the one that is medial and caudal; therefore, any combination placing the lower pole ureter in those positions is anatomically incorrect according to the rule. ### **Clinical Pearls for NEET-PG** * **The "Rule of 2s" for Complications:** * **Upper Pole Ureter:** Typically ends in an **Ectopic** insertion or a **Ureterocele**. It is prone to **Obstruction**. * **Lower Pole Ureter:** Has a shorter intramural tunnel. It is prone to **Vesicoureteral Reflux (VUR)**. * **Mnemonic:** *"Lower is Lateral"* (The lower pole ureter is the lateral one). * **Exceptions:** The Weigert-Meyer rule is followed in approximately 90% of cases of complete duplication; rare exceptions exist but are not typically tested in NEET-PG.

Question 435: What is the commonest cause of acute folliculitis (hair follicle infection)?

A. Staphylococcus aureus (Correct Answer)
B. Beta hemolytic streptococcus
C. Propionibacterium acnes
D. Streptococcus viridans

Explanation: **Explanation:** **Folliculitis** is the inflammation or infection of the hair follicle. The most common etiology is bacterial, and among bacterial causes, **Staphylococcus aureus** is the most frequent pathogen isolated globally. 1. **Why Staphylococcus aureus is correct:** *S. aureus* is a commensal organism found on the skin and in the nares. It easily invades the follicular opening, especially following friction, shaving, or occlusion, leading to the formation of a follicular pustule surrounded by an erythematous halo. 2. **Why the other options are incorrect:** * **Beta-hemolytic Streptococcus:** While a common cause of spreading skin infections like cellulitis and erysipelas, it is rarely the primary cause of localized follicular infections. * **Propionibacterium acnes (now Cutibacterium acnes):** This is the primary organism involved in the pathogenesis of **Acne Vulgaris**, not general acute folliculitis. * **Streptococcus viridans:** These are typically commensals of the oral cavity and are associated with dental caries and subacute bacterial endocarditis, not primary skin infections. **High-Yield Clinical Pearls for NEET-PG:** * **Hot Tub Folliculitis:** Caused by *Pseudomonas aeruginosa*; typically occurs after exposure to contaminated water. * **Sycosis Barbae:** A deep, chronic staphylococcal infection of the beard area. * **Furuncle (Boil):** A deep-seated infection of a single hair follicle, usually caused by *S. aureus*. * **Carbuncle:** A cluster of interconnected furuncles involving the subcutaneous tissue, most common on the nape of the neck and back; frequently associated with **Diabetes Mellitus**.

Question 436: Inadvertent surgical occlusion of the ureter leads to which of the following?

A. Complete renal atrophy
B. Hematuria
C. Renal failure
D. Hydronephrosis (Correct Answer)

Explanation: ### Explanation **Correct Option: D. Hydronephrosis** When a ureter is inadvertently occluded (e.g., during pelvic surgeries like hysterectomy), the outflow of urine from the kidney is blocked. This leads to an increase in hydrostatic pressure within the renal pelvis and calyces. As urine continues to be produced but cannot drain, the collecting system undergoes progressive dilatation, a condition known as **hydronephrosis**. If the obstruction is acute and complete, the backpressure eventually reduces the glomerular filtration rate (GFR) to protect the renal parenchyma, but the initial and hallmark anatomical change is dilatation. **Analysis of Incorrect Options:** * **A. Complete renal atrophy:** While chronic, long-standing obstruction can eventually lead to cortical thinning and "obstructive nephropathy," the immediate and primary result is dilatation (hydronephrosis), not immediate atrophy. * **B. Hematuria:** Hematuria is more commonly associated with the *cause* of an obstruction (like a stone or malignancy) or the *release* of an obstruction, rather than the occlusion itself. * **C. Renal failure:** Unilateral ureteral occlusion does not typically cause systemic renal failure (elevated creatinine) because the contralateral healthy kidney compensates. Renal failure only occurs if the obstruction is bilateral or occurs in a solitary functioning kidney. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of ureteral injury:** The point where the ureter crosses the **uterine artery** (Water under the bridge) or at the pelvic brim near the infundibulopelvic ligament. * **Early Sign:** Postoperative flank pain and fever are early indicators of accidental ligation. * **Investigation of Choice:** An **Ultrasound** is the initial screening tool to detect hydronephrosis, while an **IVP or CT Urogram** helps localize the site of occlusion.

Question 437: What treatment is used for lower ureteric stones?

A. Endoscopic removal (Correct Answer)
B. Diuretics
C. Drug dissolution
D. Laser

Explanation: **Explanation:** The management of ureteric stones depends primarily on the size and location of the calculus. For **lower ureteric stones** (distal ureter), **Endoscopic removal** via **Ureteroscopy (URS)** is the gold standard and treatment of choice. **1. Why Endoscopic Removal is Correct:** Ureteroscopy allows for direct visualization of the stone. Once identified, the stone can be extracted using a basket or fragmented (lithotripsy) if it is too large to be removed intact. It has a high success rate (stone-free rate) for distal stones compared to Extracorporeal Shock Wave Lithotripsy (ESWL), which is less effective in the bony pelvis due to localization difficulties. **2. Why Other Options are Incorrect:** * **Diuretics:** These increase urine volume but do not provide the mechanical force necessary to expel an impacted stone. In fact, they may worsen pain (renal colic) by increasing proximal hydrostatic pressure. * **Drug Dissolution:** This is only applicable for **Uric Acid stones** (using alkalinization of urine). Most ureteric stones are Calcium Oxalate, which cannot be dissolved medically. * **Laser:** While Holmium:YAG laser is the *energy source* used during endoscopy to fragment stones, "Laser" itself is a tool, not the procedure. The procedure is "Endoscopic removal" (URS). **High-Yield Clinical Pearls for NEET-PG:** * **Stone Size:** Stones **<5 mm** usually pass spontaneously with Medical Expulsive Therapy (MET) using Alpha-blockers (e.g., Tamsulosin). * **Upper/Middle Ureter:** ESWL is often the first-line for stones <1 cm; URS is preferred for stones >1 cm. * **Lower Ureter:** URS is superior to ESWL regardless of size. * **Gold Standard Investigation:** Non-Contrast Computed Tomography (NCCT) KUB.

Question 438: A 42-year-old patient presents with testicular swelling and lymphadenopathy. Which of the following investigations should NOT be performed?

A. Testicular biopsy (Correct Answer)
B. Clinical examination
C. Prostate-rectal examination
D. Contrast-enhanced computed tomography (CECT)

Explanation: **Explanation:** In any patient presenting with a testicular mass suspicious of malignancy, a **Testicular Biopsy is strictly contraindicated.** **1. Why Testicular Biopsy is NOT performed (Correct Answer):** The primary reason is the risk of **scrotal seeding** and alteration of lymphatic drainage. The testis normally drains into the **paraaortic lymph nodes**, while the scrotum drains into the **inguinal lymph nodes**. Performing a biopsy (transscrotal approach) violates the tunica albuginea and the scrotal wall, potentially spreading tumor cells to the inguinal region. This changes the clinical stage and complicates the surgical management. The definitive diagnosis and treatment are performed via a **Radical Inguinal Orchidectomy**. **2. Why other options are incorrect:** * **Clinical Examination:** This is the mandatory first step. A painless, firm-to-hard testicular mass that does not transilluminate is a classic sign of malignancy. * **Prostate-rectal Examination:** This is part of a comprehensive urological physical exam to rule out local spread or associated pathology, especially in older patients. * **CECT:** Contrast-enhanced CT of the abdomen and pelvis is the gold standard for **staging** testicular cancer, as it identifies retroperitoneal (paraaortic) lymphadenopathy and distant metastasis. **Clinical Pearls for NEET-PG:** * **Standard of Care:** Radical Inguinal Orchidectomy (clamping the spermatic cord at the internal inguinal ring first). * **Lymphatic Drainage:** Testis → Paraaortic nodes; Scrotum → Superficial Inguinal nodes. * **Tumor Markers:** LDH, AFP (never raised in pure seminoma), and beta-hCG are essential for diagnosis and monitoring. * **Initial Imaging:** Scrotal Ultrasound is the first-line imaging modality (high sensitivity).

Question 439: Persistent priapism is rarely seen as a consequence of which of the following?

A. Sickle cell disease
B. Leukemia
C. Spinal cord disease (Correct Answer)
D. Prolonged sexual activity

Explanation: **Explanation:** Priapism is defined as a persistent, usually painful, penile erection lasting more than 4 hours, unrelated to sexual stimulation. It is broadly classified into **Ischemic (Low-flow)** and **Non-ischemic (High-flow)** types. **Why Spinal Cord Disease is the Correct Answer:** While spinal cord injuries or diseases (e.g., autonomic dysreflexia, transverse myelitis) can cause priapism, it is typically **transient** and resolves as the initial spinal shock phase passes or the stimulus is removed. It rarely results in "persistent" or chronic priapism compared to hematological or mechanical causes. **Analysis of Incorrect Options:** * **Sickle Cell Disease (SCD):** This is the most common cause of ischemic priapism in children. Sickled RBCs cause venous stasis and occlusion within the corpora cavernosa, leading to prolonged, painful episodes. * **Leukemia:** Hyperleukocytosis (extremely high WBC count) increases blood viscosity, leading to mechanical obstruction of the venous outflow from the penis, a classic cause of persistent ischemic priapism. * **Prolonged Sexual Activity:** While less common than medical triggers, excessive physical trauma or prolonged stimulation can lead to high-flow priapism (often due to a ruptured cavernosal artery) or secondary inflammation that sustains an erection. **High-Yield Clinical Pearls for NEET-PG:** * **Ischemic Priapism (Low-flow):** A surgical emergency. Blood gas analysis of the corpora shows **Hypoxia, Hypercapnia, and Acidosis** (Dark blood). * **Non-Ischemic Priapism (High-flow):** Usually follows trauma; blood gas shows normal oxygen levels (Bright red blood). Not an emergency. * **Treatment Gold Standard:** Aspiration and irrigation followed by intracavernosal injection of **Phenylephrine** (alpha-agonist). * **Most common drug cause:** Intracavernosal injections for ED (e.g., Papaverine) and psychotropic drugs (e.g., Trazodone).

Question 440: Paradoxical aciduria (the excretion of acid urine in the presence of metabolic alkalosis) may occur in the presence of?

A. Syndrome of inappropriate antidiuretic hormone secretion
B. Severe crush injury
C. Acute tubular necrosis
D. Gastric outlet obstruction (Correct Answer)

Explanation: **Explanation:** **Paradoxical Aciduria** is a classic clinical phenomenon seen in **Gastric Outlet Obstruction (GOO)**, such as in cases of Infantile Hypertrophic Pyloric Stenosis or obstructing peptic ulcers. **Mechanism in Gastric Outlet Obstruction:** 1. **Metabolic Alkalosis:** Persistent vomiting leads to a massive loss of $H^+$ and $Cl^-$ ions, resulting in hypochloremic metabolic alkalosis. 2. **Dehydration and Hypovolemia:** Loss of fluid triggers the Renin-Angiotensin-Aldosterone System (RAAS). Aldosterone acts on the distal tubule to reabsorb $Na^+$ in exchange for $K^+$. 3. **Hypokalemia:** As $K^+$ is depleted due to both vomiting and renal loss, the kidneys are forced to conserve $K^+$. 4. **The "Paradox":** To continue reabsorbing $Na^+$ (to maintain blood pressure) when $K^+$ is no longer available, the distal tubule begins secreting $H^+$ ions into the urine instead. Thus, despite the body being in a state of alkalosis, the urine becomes acidic. **Analysis of Incorrect Options:** * **SIADH:** Characterized by hyponatremia and concentrated urine, but does not typically cause metabolic alkalosis or paradoxical aciduria. * **Severe Crush Injury:** Leads to Rhabdomyolysis, hyperkalemia, and **metabolic acidosis** (due to release of intracellular organic acids). * **Acute Tubular Necrosis (ATN):** Results in the inability of the tubules to concentrate urine or maintain pH gradients, usually leading to metabolic acidosis. **High-Yield Clinical Pearls for NEET-PG:** * **The Triad of GOO:** Hypochloremic, hypokalemic, metabolic alkalosis with paradoxical aciduria. * **Initial Fluid of Choice:** Normal Saline (0.9% NaCl). It addresses the volume deficit and provides $Cl^-$ to correct the alkalosis. * **Correction:** Potassium should be supplemented only after ensuring adequate urine output.

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