Urology Practice Questions

Q: PSA is measured in which units?

ng/ml. **Explanation:** **Prostate-Specific Antigen (PSA)** is a glycoprotein enzyme secreted by the epithelial cells of the prostate gland. In clinical practice, PSA is a vital biomarker used for the screening, diagnosis, and monitoring of prostate cancer and other prostatic conditions. **1. Why ng/ml is the correct answer:** PSA circulates in the blood in very minute quantities. The standard unit of measurement for PSA is **nanograms per milliliter (ng/ml)**. In a healthy individual with a normal-sized prostate, the typical "normal" reference range is generally considered to be **0–4 ng/ml**. Because the concentration is so low, using larger units would result in impractical decimal values. **2. Why other options are incorrect:** * **gm/ml (Grams), mg/ml (Milligrams), and mcg/ml (Micrograms):** These units represent much higher concentrations (1 mg is $10^6$ times larger than 1 ng). Measuring PSA in these units would yield values like 0.000000004 gm/ml, which is clinically unusable. These units are typically reserved for serum proteins (like albumin in gm/dl) or drug concentrations, rather than trace tumor markers. **3. Clinical Pearls for NEET-PG:** * **Age-Specific PSA:** PSA levels naturally rise with age due to increasing prostate volume (e.g., 0.75 ng/ml per year** is highly suspicious for malignancy, even if the total PSA is 25%) suggests BPH. * **Causes of Elevated PSA:** Apart from Prostate Cancer, PSA can be elevated in BPH, Prostatitis, Urinary Tract Infections (UTI), and following procedures like DRE, cystoscopy, or prostatic biopsy.

Q: A 49-year-old male with a 35-pack-year smoking history presents with a painless left scrotal mass. Examination revealed microscopic hematuria and normal alpha-fetoprotein (AFP) and lactate dehydrogenase (LDH) levels. What is the most probable cause of the scrotal mass?

Renal cell carcinoma. ### Explanation The correct answer is **Renal Cell Carcinoma (RCC)**. **1. Why Renal Cell Carcinoma is correct:** The clinical presentation of a **painless scrotal mass** (specifically a varicocele) associated with **microscopic hematuria** and a significant **smoking history** is a classic "red flag" for Renal Cell Carcinoma. * **The Anatomical Link:** A left-sided varicocele occurs in RCC when the tumor invades the renal vein or causes extrinsic compression, obstructing the drainage of the **left gonadal (testicular) vein**, which drains directly into the left renal vein at a 90-degree angle. * **Clues in the stem:** Hematuria is the most common presenting sign of RCC. The normal AFP and LDH levels help rule out primary germ cell tumors. **2. Why other options are incorrect:** * **Seminoma:** While it presents as a painless scrotal mass, it typically presents in younger men (30–40s) and would not explain the microscopic hematuria. * **Epididymitis:** This usually presents with acute scrotal pain, fever, and signs of inflammation (Prehn’s sign positive), rather than a painless mass and hematuria. * **Carcinoma of the lung:** While the patient is a smoker, lung cancer does not typically present with a scrotal mass or hematuria unless there is widespread metastasis, which is less likely than a primary renal pathology in this context. **3. Clinical Pearls for NEET-PG:** * **Left vs. Right Varicocele:** A **new-onset left varicocele** in an older male that does not empty when lying supine must be investigated for RCC. A **right-sided varicocele** is even more concerning as it is rarer (the right gonadal vein drains directly into the IVC) and often indicates a retroperitoneal mass or IVC obstruction. * **Classic Triad of RCC:** Hematuria, flank pain, and a palpable mass (seen in only 10% of cases). * **Stauffer Syndrome:** A paraneoplastic syndrome of RCC involving non-metastatic hepatic dysfunction.

Q: What is the drug of choice for renal colic?

Diclofenac. **Explanation:** The management of renal colic focuses on relieving pain and reducing ureteral smooth muscle spasms. **Why Diclofenac is the Correct Answer:** Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), specifically **Diclofenac**, are the **first-line drug of choice** for acute renal colic. The underlying pathophysiology of renal colic involves an increase in intrapelvic pressure due to obstruction, which triggers the release of **Prostaglandins**. Prostaglandins cause further vasodilation (increasing glomerular filtration and pressure) and direct ureteral smooth muscle contraction. Diclofenac inhibits the enzyme cyclooxygenase (COX), thereby blocking prostaglandin synthesis. This reduces ureteral edema, lowers intrarenal pressure, and provides superior analgesia compared to opioids in this specific clinical setting. **Analysis of Incorrect Options:** * **Methadone (A):** A long-acting synthetic opioid primarily used for chronic pain management and opioid detoxification. It is not indicated for acute renal colic. * **Pentazocine (B):** An opioid agonist-antagonist. While it provides analgesia, opioids can cause unwanted side effects like nausea and, theoretically, may increase ureteral pressure or cause spasm of the Sphincter of Oddi. * **Piroxicam (D):** Although an NSAID, it has a slower onset of action and a longer half-life, making it less suitable for the rapid relief required in acute renal colic compared to Diclofenac. **Clinical Pearls for NEET-PG:** * **Route of Administration:** Intramuscular (IM) or intravenous (IV) Diclofenac is preferred for rapid onset, though rectal suppositories are also highly effective. * **Second-line:** If NSAIDs are contraindicated (e.g., renal failure, peptic ulcer disease) or ineffective, opioids (like Morphine or Pethidine) are used. * **Medical Expulsive Therapy (MET):** For stones <10mm, **Tamsulosin** (Alpha-1 blocker) is the drug of choice to facilitate stone passage.

Q: On exertion, in which condition does the urine stream increase?

Urethral stricture. ### Explanation In **Urethral Stricture**, the pathology is a fixed, anatomical narrowing of the urethral lumen due to scarring (fibrosis). When a patient with a stricture exerts themselves (e.g., using the Valsalva maneuver or abdominal straining), the intra-abdominal pressure increases. This pressure is transmitted directly to the bladder, increasing the intravesical pressure. Because the stricture is a **passive, rigid resistance**, the increased driving force from the bladder successfully pushes more urine through the narrow opening, thereby **increasing the force and flow of the urine stream**. **Why the other options are incorrect:** * **Prostate Enlargement (BPH):** This is a "dynamic" obstruction. Straining increases pressure on the pelvic floor, which can further compress the prostatic urethra or cause the enlarged median lobe to act as a ball-valve, often worsening the obstruction rather than improving the stream. * **Marion’s Disease (Bladder Neck Obstruction):** This involves hypertrophy or lack of relaxation of the internal sphincter. Like BPH, it acts as a functional/dynamic valve where straining does not significantly improve the flow and may worsen the dysfunction. * **Posterior Urethral Valves (PUV):** These are mucosal folds in the distal prostatic urethra that act as **one-way valves**. Increased abdominal pressure pushes the valve leaflets together, further sealing the lumen and worsening the obstruction. ### Clinical Pearls for NEET-PG: * **Urethral Stricture:** Most common site is the **bulbar urethra** (post-traumatic or idiopathic). The gold standard investigation is **Retrograde Urethrogram (RGU)**. * **Flow Rate:** A peak flow rate (**Qmax**) of **<10 mL/s** is highly suggestive of significant outflow obstruction. * **Key Distinction:** If the stream improves with straining, think **Stricture**; if it worsens or remains poor despite straining, think **Prostatic or Valve obstruction**.

Q: An elderly male presents with one episode of gross hematuria. Which of the following investigations is NOT recommended for investigating this patient?

Urine tumor markers. The primary goal in evaluating an elderly patient with gross hematuria is to rule out malignancy, specifically **Urothelial Carcinoma** (Bladder Cancer) or **Renal Cell Carcinoma**. [1] **Why Option C is the Correct Answer (NOT recommended):** While several urine tumor markers (e.g., NMP22, BTA stat) exist, they are **not recommended** for the initial diagnostic workup of hematuria according to AUA and EAU guidelines. They lack the necessary sensitivity and specificity to replace gold-standard investigations and often yield false positives in the presence of stones, infection, or inflammation. **Why the other options are wrong (Recommended investigations):** * **Cystoscopy (A):** This is the gold standard for evaluating the lower urinary tract. It is mandatory in patients >35 years with gross hematuria to visualize bladder tumors that imaging might miss. * **Urine microscopy for malignant cells (B):** Urine cytology has high specificity for detecting high-grade urothelial carcinoma and CIS (Carcinoma in situ). [1] * **Intravenous Pyelogram (D):** Historically, IVP was the standard for imaging the upper tract (ureters and renal pelvis). While largely replaced by **CT Urography** in modern practice, it remains a valid classical investigation for upper tract morphology in exams. **Clinical Pearls for NEET-PG:** * **Rule of Thumb:** Any painless gross hematuria in an elderly patient is **Bladder Cancer** until proven otherwise. [1] * **Initial Investigation of Choice:** Ultrasonography (KUB) is often the first step, but **CT Urography** is the most sensitive imaging for the upper tract. [2] * **Most common cause of hematuria (overall):** Urinary Tract Infection (UTI). * **Most common cause of hematuria (elderly):** Bladder malignancy or BPH.

Q: What is the drug of choice for surgically unresectable renal cell carcinoma?

Sunitinib. ### Explanation **Correct Answer: B. Sunitinib** **Medical Concept:** Renal Cell Carcinoma (RCC) is a highly vascular tumor characterized by the overexpression of **Vascular Endothelial Growth Factor (VEGF)**, often due to mutations in the *VHL* (von Hippel-Lindau) gene. For metastatic or surgically unresectable RCC, traditional chemotherapy and radiotherapy are largely ineffective. The mainstay of treatment is **Targeted Therapy**. **Sunitinib** is a multi-targeted tyrosine kinase inhibitor (TKI) that inhibits VEGF receptors (VEGFR) and Platelet-Derived Growth Factor receptors (PDGFR). It has historically been the first-line drug of choice for advanced/metastatic clear cell RCC because it inhibits the angiogenesis that drives tumor growth. **Analysis of Incorrect Options:** * **A. Sorafenib:** While also a TKI used in RCC, it is generally considered a second-line agent or used when Sunitinib is not tolerated. It is more commonly associated with Hepatocellular Carcinoma (HCC). * **C. Imatinib:** This TKI specifically targets BCR-ABL, c-KIT, and PDGFR. It is the drug of choice for **Chronic Myeloid Leukemia (CML)** and **Gastrointestinal Stromal Tumors (GIST)**, not RCC. * **D. Cetuximab:** This is a monoclonal antibody against **EGFR**. It is used in Colorectal Cancer and Head and Neck Squamous Cell Carcinoma, but has no role in the management of RCC. **High-Yield Clinical Pearls for NEET-PG:** * **Most common histological type:** Clear cell RCC (80%). * **First-line for Metastatic RCC:** Sunitinib or Pazopanib. (Note: Recent guidelines also include immunotherapy combinations like Axitinib + Pembrolizumab). * **Common Side Effect of Sunitinib:** Hand-foot syndrome, hypertension, and fatigue. * **Interleukin-2 (IL-2):** Previously used as immunotherapy but now largely replaced due to high toxicity. * **Temsirolimus:** An mTOR inhibitor used specifically for "poor prognosis" metastatic RCC.

Q: A male patient presents with acute scrotal pain. Which investigation is most effective in differentiating between testicular torsion and epididymo-orchitis?

Color Doppler. **Explanation:** The clinical differentiation between **testicular torsion** (a surgical emergency) and **epididymo-orchitis** (an inflammatory condition) is critical. The gold standard imaging modality for this purpose is **Color Doppler Ultrasonography (CDUS)**. 1. **Why Color Doppler is Correct:** The underlying pathophysiology differs significantly in terms of vascularity. In **testicular torsion**, the twisting of the spermatic cord leads to ischemia, appearing as **absent or decreased blood flow** on Doppler. In contrast, **epididymo-orchitis** is an inflammatory process characterized by hyperemia, showing **increased blood flow** to the testis and epididymis. CDUS has a high sensitivity (82-100%) and specificity (88-100%) for this distinction. 2. **Why other options are incorrect:** * **Angel sign:** This refers to the horizontal lie of the contralateral testis in a patient with torsion. While a useful clinical observation, it is not a definitive "investigation." * **Prehn sign:** This is a physical exam finding where pain is relieved by elevating the scrotum (suggestive of epididymitis) but not in torsion. However, it is notoriously **unreliable** and cannot be used to rule out torsion. * **MRI:** While highly accurate, MRI is time-consuming, expensive, and not readily available in emergency settings. Since "time is muscle" in torsion (6-hour golden window), MRI is not the investigation of choice. **Clinical Pearls for NEET-PG:** * **Golden Window:** Testicular salvage rates are >90% if detorsion occurs within 6 hours, dropping to <10% after 24 hours. * **Management:** If clinical suspicion for torsion is very high, do not delay surgery for imaging; proceed directly to **emergency scrotal exploration**. * **Radionuclide Scan:** Historically used to show "cold spots" in torsion, but largely replaced by Doppler due to availability.

Question 1

PSA is measured in which units?

Accepted Answer

ng/ml

Answer

gm/ml

Answer

mg/ml

Answer

mcg/ml

Question 2

A 49-year-old male with a 35-pack-year smoking history presents with a painless left scrotal mass. Examination revealed microscopic hematuria and normal alpha-fetoprotein (AFP) and lactate dehydrogenase (LDH) levels. What is the most probable cause of the scrotal mass?

Accepted Answer

Renal cell carcinoma

Answer

Seminoma

Answer

Epididymitis

Answer

Carcinoma of the lung

Question 3

What is the drug of choice for renal colic?

Accepted Answer

Diclofenac

Answer

Methadone

Answer

Pentazocine

Answer

Piroxicam

Question 4

On exertion, in which condition does the urine stream increase?

Accepted Answer

Urethral stricture

Answer

Prostate enlargement

Answer

Marion's disease

Answer

Posterior urethral valves

Question 5

An elderly male presents with one episode of gross hematuria. Which of the following investigations is NOT recommended for investigating this patient?

Accepted Answer

Urine tumor markers

Answer

Cystoscopy

Answer

Urine microscopy for malignant cells

Answer

Intravenous pyelogram

Question 6

What is the drug of choice for surgically unresectable renal cell carcinoma?

Accepted Answer

Sunitinib

Answer

Sorafenib

Answer

Imatinib

Answer

Cetuximab

Question 7

A male patient presents with acute scrotal pain. Which investigation is most effective in differentiating between testicular torsion and epididymo-orchitis?

Accepted Answer

Color Doppler

Answer

Angel sign

Answer

Prehn sign

Answer

MRI

Question 8

A 10-mm calculus in the right lower ureter associated with proximal hydroureteronephrosis is best treated with?

Accepted Answer

Ureteroscopic retrieval

Answer

Extracorporeal shockwave lithotripsy

Answer

Antegrade percutaneous access

Answer

Open ureterolithotomy

Question 9

A 70-year-old male chronic smoker is diagnosed with cancer of the urinary bladder, confined to the trigone with extension up to the submucosa. What is the recommended management?

Accepted Answer

Complete transurethral resection with intravesical chemotherapy

Answer

Complete transurethral resection

Answer

Palliative radiotherapy

Answer

Radical cystectomy

Question 10

Which of the following is true of blunt renal trauma?

Accepted Answer

Blunt renal trauma requires exploration only when the patient exhibits hemodynamic instability.

Answer

Blunt renal trauma and penetrating renal injuries are managed similarly.

Answer

Blunt renal trauma must be evaluated by contrast studies using either IVP or CT.

Answer

Any kidney fractured by blunt renal trauma must be explored.

Urology — MCQs

Urology — MCQs

On this page

Practice by Chapter

Want unlimited practice?