Urology Practice Questions

Q: Hunner's ulcer is typically seen in which part of the urinary tract?

Bladder. **Explanation:** **Hunner’s ulcers** are a hallmark finding in **Interstitial Cystitis (IC)**, also known as Bladder Pain Syndrome. These are not true ulcers in the traditional sense but rather distinct inflammatory lesions characterized by circumscribed, reddened mucosal areas with small vessels radiating towards a central scar. When the bladder is distended during cystoscopy, these lesions often crack and bleed (the "cascade bleeding" sign). * **Why Bladder is Correct:** Interstitial cystitis is a chronic inflammatory condition specifically affecting the **bladder wall**. Hunner’s ulcers are found in approximately 5–10% of IC cases, typically located on the bladder dome or lateral walls. * **Why other options are incorrect:** * **Ureter & Urethra:** While these structures are part of the lower urinary tract, they do not develop Hunner’s ulcers. Ureteral pathology usually involves calculi or transitional cell carcinoma, while urethral pathology involves strictures or urethritis. * **Kidney:** Renal pathology involves the parenchyma or collecting system (e.g., glomerulonephritis or pyelonephritis), which is physiologically and histologically distinct from the inflammatory process of IC. **High-Yield Clinical Pearls for NEET-PG:** 1. **Glomerulations:** These are "strawberry-like" petechial hemorrhages seen on the bladder mucosa after hydrodistension; they are more common but less specific than Hunner’s ulcers for IC. 2. **Clinical Triad:** Increased urinary frequency, urgency, and pelvic pain (relieved by voiding). 3. **Demographics:** Predominantly affects middle-aged women. 4. **Diagnosis:** It is a diagnosis of exclusion. Cystoscopy with hydrodistension is the classic diagnostic maneuver. 5. **Treatment:** First-line includes lifestyle changes; **Pentosan Polysulfate Sodium** is the only FDA-approved oral drug. Intravesical instillations (e.g., DMSO) are also used.

Q: A young male falls from 15 feet and develops a perineal hematoma and suprapubic mass. Which of the following structures is most likely injured?

Urethra. **Explanation:** The clinical presentation of a **perineal hematoma** (often described as a "butterfly hematoma") and a **suprapubic mass** (representing a distended urinary bladder) in a trauma patient is a classic triad for **Urethral Injury**. 1. **Why Urethra is Correct:** In young males, a fall from a height often results in a "straddle injury," causing the bulbar urethra to be crushed against the pubic symphysis. If the **Buck’s fascia** is ruptured, urine and blood extravasate into the superficial perineal pouch, limited by Colles' fascia, leading to a perineal hematoma. The inability to void results in acute urinary retention, which presents as a palpable **suprapubic mass** (distended bladder). 2. **Why other options are incorrect:** * **Urinary Bladder:** While a bladder rupture can cause a suprapubic mass (if extraperitoneal), it typically does not present with a perineal hematoma unless associated with complex pelvic fractures. * **Anus:** Anal injuries present with rectal bleeding or sphincter dysfunction, not urinary retention or a suprapubic mass. * **Rectus Abdominis:** A rectus sheath hematoma can cause a suprapubic mass, but it would not cause a perineal hematoma or interfere with voiding. **High-Yield Clinical Pearls for NEET-PG:** * **Anterior Urethral Injury (Bulbar):** Most common cause is a straddle injury. Key sign: Butterfly perineal hematoma. * **Posterior Urethral Injury (Membranous):** Most common cause is Pelvic Fracture. Key sign: **High-riding prostate** on DRE. * **Gold Standard Investigation:** Retrograde Urethrogram (RUG). * **Management:** Do **NOT** insert a Foley catheter if urethral injury is suspected (blood at meatus). Perform a Suprapubic Cystostomy (SPC) instead.

Q: What is the most indicative test for prostate cancer?

Prostate-specific antigen (PSA). **Explanation:** **Prostate-specific antigen (PSA)** is the most indicative and widely used screening marker for prostate cancer. PSA is a serine protease produced by the ductal and acinar epithelium of the prostate. While it is organ-specific, it is not cancer-specific (levels can rise in BPH or prostatitis); however, a level **>4 ng/mL** significantly increases the suspicion of malignancy, and values **>10 ng/mL** are highly indicative of cancer, necessitating a biopsy. **Analysis of Options:** * **Digital Rectal Examination (DRE):** While crucial, DRE is subjective and often misses early-stage tumors located deep within the peripheral zone or those that are not yet palpable (T1 stage). * **Magnetic Resonance Imaging (MRI):** Multiparametric MRI (mpMRI) is excellent for localization and staging (PI-RADS scoring), but it is not the primary indicative screening test due to cost and accessibility. * **Excretory Urography (IVP):** This is largely obsolete for prostate cancer. It may show a "hooking of ureters" or a filling defect in the bladder base, but these are non-specific signs of prostatic enlargement. **Clinical Pearls for NEET-PG:** * **Gold Standard for Diagnosis:** Transrectal Ultrasound (TRUS) guided systematic **12-core biopsy**. * **Most Common Site:** Peripheral zone (70%). * **PSA Velocity:** A rise of **>0.75 ng/mL/year** is suspicious even if the total PSA is <4 ng/mL. * **Free-to-Total PSA Ratio:** A lower ratio (<10-15%) is more indicative of malignancy than BPH. * **Osteoblastic Metastases:** Prostate cancer characteristically spreads to the bone (lumbar spine), causing sclerotic/dense lesions.

Q: Which of the following is NOT a complication of the irrigating fluid used in Transurethral Resection of the Prostate (TURP)?

Hyperthermia. In TURP, large volumes of irrigating fluid are used to maintain visibility and distend the bladder. These fluids can be absorbed into the systemic circulation through opened prostatic venous sinuses, leading to specific metabolic and systemic complications. **Explanation of the Correct Answer:** **C. Hyperthermia** is the correct answer because TURP is actually associated with **Hypothermia**, not hyperthermia. The irrigation fluid is typically stored at room temperature (around 20-22°C), which is significantly lower than body temperature. Large-scale absorption and continuous irrigation lead to core body heat loss. **Analysis of Incorrect Options:** * **A. Water Intoxication:** Using non-electrolyte solutes like Glycine or Sorbitol in water can lead to "TURP Syndrome." Excessive absorption causes dilutional hyponatremia and fluid overload, manifesting as confusion, visual disturbances, and seizures. * **B. Hyperammonemia:** This is a specific complication of **1.5% Glycine** irrigation. Glycine is metabolized in the liver into ammonia. Elevated levels can cross the blood-brain barrier, causing encephalopathy and delayed recovery from anesthesia. * **D. Hyperglycemia:** This occurs when **Sorbitol** is used as the irrigating fluid. Sorbitol is metabolized into fructose and then glucose, which can lead to elevated blood sugar levels, particularly concerning in diabetic patients. **Clinical Pearls for NEET-PG:** * **Ideal Irrigant:** Isotonic (Normal Saline) is ideal but can only be used with **Bipolar TURP** (to prevent electrical dissipation). Monopolar TURP requires non-conducting fluids (Glycine, Sorbitol, Mannitol). * **TURP Syndrome Triad:** Hypertension (early), Bradycardia, and Mental status changes (due to hyponatremia). * **Visual Loss:** Transient blindness post-TURP is specifically associated with Glycine toxicity affecting the retina.

Q: What are the common complications of ureterosigmoidostomy?

Hyperchloremic with hypokalemic acidosis. **Explanation:** Ureterosigmoidostomy is a form of urinary diversion where the ureters are implanted into the sigmoid colon. While largely replaced by ileal conduits, it remains a high-yield topic in NEET-PG due to its classic metabolic complications. **Why Option A is correct:** The primary complication is **Hyperchloremic Hypokalemic Metabolic Acidosis**. This occurs due to the prolonged contact of urine with the colonic mucosa: 1. **Chloride/Bicarbonate Exchange:** The colonic mucosa actively reabsorbs chloride ions from the urine in exchange for bicarbonate ions, leading to bicarbonate loss and systemic acidosis. 2. **Ammonium Reabsorption:** The bowel reabsorbs urinary ammonium ($NH_4^+$), which is metabolized in the liver to urea and hydrogen ions, further worsening the acidosis. 3. **Potassium Loss:** To maintain electrical neutrality and due to the secretory nature of the colon, potassium is excreted into the bowel lumen and lost in the stool, resulting in hypokalemia. **Why other options are incorrect:** * **B & C:** Metabolic alkalosis and hyperkalemia are physiologically opposite to the effects of colonic urinary diversion. * **D:** While minor electrolyte shifts occur, hyponatremia is not the hallmark metabolic derangement of this procedure. **High-Yield Clinical Pearls for NEET-PG:** * **Late Complication:** The most dreaded long-term complication is **Adenocarcinoma of the colon** (usually at the site of ureteric implantation), occurring 10–20 years post-surgery. * **Other Complications:** Ascending pyelonephritis (due to fecal reflux), urolithiasis, and growth retardation in children. * **Contraindication:** It should never be performed in patients with a weak anal sphincter, as it leads to total urinary/fecal incontinence.

Q: What is the commonest cause of urethral stricture in a young person?

Trauma. **Explanation:** The epidemiology of urethral strictures has shifted significantly in recent decades. In modern clinical practice, **Trauma** is the most common cause of urethral strictures in young individuals in developed and developing nations alike. 1. **Why Trauma is Correct:** In young patients, trauma typically occurs via two mechanisms: **Straddle injuries** (falling astride an object), which lead to bulbar urethral strictures, and **Pelvic fractures** (often from motor vehicle accidents), which typically cause posterior urethral distractions. These injuries lead to scarring and fibrosis of the urethral corpus spongiosum (spongiofibrosis), resulting in a narrowed lumen. 2. **Why Incorrect Options are Wrong:** * **Gonococcal infection:** Historically, this was the leading cause worldwide. However, with the advent of effective antibiotic therapy, post-inflammatory strictures have become less common, though they remain a significant cause in specific geographic regions. * **Syphilis and Tuberculosis:** These are extremely rare causes of urethral strictures. Syphilis rarely involves the urethra in a way that leads to stricture, and TB typically affects the upper urinary tract or the prostate/epididymis rather than the penile urethra. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of Traumatic stricture:** Bulbar urethra (following straddle injury). * **Most common site of Post-TURP stricture:** Fossa navicularis or bladder neck. * **Gold Standard Investigation:** Retrograde Urethrogram (RUG) combined with Voiding Cystourethrogram (VCUG) to define the length and location. * **Management:** Short strictures (<2cm) are often treated with **Direct Vision Internal Urethrotomy (DVIU)**; longer or recurrent strictures require **Urethroplasty** (e.g., Buccal Mucosa Graft).

Q: Which of the following are features of membranous urethral injury?

All of the above. ### Explanation The **membranous urethra** is the shortest and least dilatable part of the male urethra, located within the **deep perineal pouch** where it is surrounded by the external urethral sphincter. Injury to this segment most commonly occurs due to **fracture of the bony pelvis** (e.g., road traffic accidents), leading to a partial or complete transection at the puboprostatic ligament [1]. **Why "All of the above" is correct:** 1. **Blood at the meatus:** This is the most important clinical sign of urethral injury. Disruption of the urethral mucosa leads to bleeding that tracks distally to the external urethral orifice. 2. **Extravasation of urine:** When the membranous urethra is ruptured, urine leaks into the **deep perineal pouch**. If the perineal membrane is also torn, urine can track superiorly into the prevesical space (Space of Retzius) or around the prostate [1]. 3. **Retention of urine:** The physical disruption of the urethral continuity, combined with pain and reflex spasm of the sphincters, prevents the patient from voiding, leading to acute urinary retention and a palpable bladder. **Clinical Pearls for NEET-PG:** * **High-riding Prostate:** On Digital Rectal Examination (DRE), the prostate may be non-palpable or "floating" because the puboprostatic ligaments are torn and the prostate is displaced superiorly by a pelvic hematoma, often referred to as a "pie in the sky" bladder [1]. * **Gold Standard Investigation:** **Retrograde Urethrogram (RUG)** must be performed *before* attempting catheterization to avoid converting a partial tear into a complete one [1]. * **Anatomical Landmark:** The membranous urethra is the part that pierces the **urogenital diaphragm**. * **Bulbar vs. Membranous:** While membranous injury is associated with pelvic fractures, **bulbar urethral injury** is typically caused by "straddle injuries" (falling astride) and results in a "butterfly-shaped" hematoma in the perineum [1].

Q: Regarding lipoma of the spermatic cord, which of the following is true?

All of the above. ### Explanation **Lipoma of the spermatic cord** is a common clinical entity, often encountered during inguinal hernia repairs. Despite its name, it is not a true neoplastic lipoma but rather an **extrusion of extraperitoneal fat** through the internal inguinal ring into the spermatic canal. #### Why "All of the Above" is Correct: 1. **Soft and Irregular (Option A):** Being composed of adipose tissue, the mass is characteristically soft and doughy on palpation. Unlike a tense hernia sac, it often feels lobulated or irregular. 2. **No Cough Impulse (Option B):** A true cough impulse is a feature of a patent processus vaginalis (hernia sac) where intra-abdominal pressure is transmitted directly. Since a cord lipoma is a solid fatty mass (even if it slides), it typically **lacks a true expansile cough impulse**, making it difficult to clinically distinguish from an incarcerated omental hernia. 3. **Will Not Reduce (Option C):** While the mass may slide slightly within the canal, it is anatomically attached to the cord structures or the extraperitoneal space. Unlike a simple reducible inguinal hernia, the fatty mass itself **cannot be completely reduced** into the peritoneal cavity. #### Clinical Pearls for NEET-PG: * **Most Common Benign Tumor:** Lipoma is the most common benign "tumor" of the spermatic cord. * **The "Hidden" Hernia:** It is often associated with an indirect inguinal hernia sac. If a surgeon removes a hernia sac but misses a large cord lipoma, the patient may present with a "pseudo-recurrence" due to the persistent bulge. * **Differential Diagnosis:** It must be differentiated from an **encysted hydrocele of the cord**, which is fluctuant, transilluminates, and is tense/mobile, whereas a lipoma is soft and dull to percussion. * **Management:** During hernioplasty, the lipoma should be excised or reduced to ensure a flat repair and prevent post-operative discomfort.

Question 1

Hunner's ulcer is typically seen in which part of the urinary tract?

Accepted Answer

Bladder

Answer

Ureter

Answer

Urethra

Answer

Kidney

Question 2

A young male falls from 15 feet and develops a perineal hematoma and suprapubic mass. Which of the following structures is most likely injured?

Accepted Answer

Urethra

Answer

Urinary bladder

Answer

Anus

Answer

Rectus abdominis

Question 3

What is the most indicative test for prostate cancer?

Accepted Answer

Prostate-specific antigen (PSA)

Answer

Digital rectal examination

Answer

Magnetic resonance imaging (MRI)

Answer

Excretory urography

Question 4

Which of the following is NOT a complication of the irrigating fluid used in Transurethral Resection of the Prostate (TURP)?

Accepted Answer

Hyperthermia

Answer

Water intoxication

Answer

Hyperammonemia

Answer

Hyperglycemia

Question 5

Thimble bladder is seen in which of the following conditions?

Accepted Answer

Acute tubercular cystitis

Answer

Cystitis

Answer

Chronic tubercular cystitis

Answer

Neurogenic bladder

Question 6

What are the common complications of ureterosigmoidostomy?

Accepted Answer

Hyperchloremic with hypokalemic acidosis

Answer

Hyperkalemia

Answer

Metabolic alkalosis

Answer

Hyponatremia

Question 7

What is the commonest cause of urethral stricture in a young person?

Accepted Answer

Trauma

Answer

Gonococcal infection

Answer

Syphilis

Answer

Tuberculosis

Question 8

Which of the following are features of membranous urethral injury?

Accepted Answer

All of the above

Answer

Blood at meatus

Answer

Extravasation of urine

Answer

Retention of urine

Question 9

Which of the following statements concerning carcinoma of the prostate is FALSE?

Accepted Answer

Radical prostatectomy is associated with a 5% incidence of permanent urinary incontinence.

Answer

Annual digital rectal examination and serum prostate specific antigen (PSA) determinations are recommended for screening.

Answer

Lung metastasis is less common than bone metastasis.

Answer

Once prostate cancer has spread, it is no longer curable but can be contained by lowering serum testosterone and/or by administration of androgen receptor blockers.

Question 10

Regarding lipoma of the spermatic cord, which of the following is true?

Accepted Answer

All of the above

Answer

Soft and irregular

Answer

No cough impulse

Answer

Will not reduce

Urology — MCQs

Urology — MCQs

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