Urology Practice Questions

Q: An 85-year-old man underwent transurethral resection of the prostate. Histological examination of his specimen showed T1a stage adenocarcinoma. What is the appropriate management?

No further treatment. **Explanation:** The management of prostate cancer is determined by the stage, grade, and the patient's life expectancy. In this scenario, the patient has **Stage T1a adenocarcinoma** and is **85 years old**. **1. Why "No further treatment" is correct:** * **Stage T1a Definition:** This is an incidental histological finding where the tumor involves **≤ 5% of the resected tissue** (usually following a TURP for presumed BPH). * **Prognosis & Age:** T1a tumors are typically low-grade and slow-growing. In an 85-year-old patient, the life expectancy is likely less than 10 years. Since the risk of disease progression is extremely low and the patient is more likely to die *with* the cancer than *of* it, the standard of care is **watchful waiting** or no further treatment. **2. Why other options are incorrect:** * **Radical Surgery (Radical Prostatectomy):** This is generally reserved for patients with a life expectancy of >10 years and higher-stage localized disease (T1b, T2). In an 85-year-old, the morbidity of surgery outweighs any potential survival benefit. * **Endocrine/Hormone Therapy:** These are synonymous and involve Androgen Deprivation Therapy (ADT). This is indicated for metastatic disease (Stage N+ or M+) or as an adjunct to radiotherapy in high-risk localized cases. It is not indicated for incidental T1a disease. **Clinical Pearls for NEET-PG:** * **T1a:** Incidental finding in ≤ 5% of tissue. * **T1b:** Incidental finding in > 5% of tissue. * **T1c:** Identified by needle biopsy (usually due to elevated PSA). * **Management Rule:** For T1a, if the patient is elderly/comorbid, observe. If the patient is young (life expectancy >10 years), consider follow-up or radical treatment. * **Most common site of Prostate Cancer:** Peripheral zone (unlike BPH, which occurs in the Transition zone).

Q: What is the most common cause of urethral stricture?

Trauma. **Explanation:** Urethral stricture refers to the narrowing of the urethral lumen due to fibrosis and scarring of the urethral mucosa and surrounding corpus spongiosum (spongiofibrosis). **1. Why Trauma is correct:** In modern clinical practice, **trauma** is the most common cause of urethral strictures globally. This includes: * **Iatrogenic Trauma (Most Common Subtype):** This includes injuries from urethral catheterization, transurethral surgeries (like TURP), and cystoscopy. * **External Trauma:** Straddle injuries (leading to bulbar urethral stricture) and pelvic fractures (leading to membranous urethral distractions). **2. Analysis of Incorrect Options:** * **Infection (Option B):** Historically, gonococcal urethritis was the leading cause. However, with the advent of effective antibiotics, inflammatory strictures have significantly decreased in incidence. * **Congenital (Option C):** These are rare and usually present as posterior urethral valves rather than true fibrous strictures. * **Post-endoscopy (Option D):** While a very common cause, it is technically a subset of **Iatrogenic Trauma**. In MCQ exams, "Trauma" is the broader, preferred umbrella term. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of stricture:** Bulbar urethra (especially in iatrogenic and straddle injuries). * **Gold Standard Investigation:** Retrograde Urethrogram (RUG) combined with Voiding Cystourethrogram (VCU) to define the length and location. * **Management:** * Short strictures (<2 cm): Direct Vision Internal Urethrotomy (DVIU) or dilatation. * Long/Recurrent strictures: Urethroplasty (e.g., BMG - Buccal Mucosal Graft urethroplasty). * **Pelvic Fracture:** Most commonly associated with injury to the **membranous urethra** (Posterior urethra).

Q: Which of the following conditions is NOT associated with an elevation in prostatic specific antigen?

Prostatic intraepithelial neoplasia. ### Explanation **Correct Option: C. Prostatic intraepithelial neoplasia (PIN)** The underlying medical concept is that **Prostate-Specific Antigen (PSA)** is a protease produced by the ductal and acinar epithelium of the prostate. Its elevation in the serum occurs when there is a disruption of the **prostatic-blood barrier** (basal cell layer and basement membrane). In **Prostatic Intraepithelial Neoplasia (PIN)**, particularly High-Grade PIN, there is cellular atypia within the ducts, but the **basal cell layer remains intact**. Because the architectural integrity is preserved and there is no significant tissue inflammation or necrosis, PIN does not typically cause a rise in serum PSA levels. **Analysis of Incorrect Options:** * **A. Acute Prostatitis:** Intense inflammation and infection cause significant disruption of the prostatic epithelium and cellular membranes, leading to a massive leakage of PSA into the systemic circulation. * **B. Benign Prostatic Hyperplasia (BPH):** PSA is organ-specific, not cancer-specific. In BPH, the increased volume of prostatic tissue (hyperplasia) leads to a proportional increase in PSA production. * **D. Prostatic Needle Biopsy:** Mechanical trauma and the physical breach of the prostatic-blood barrier during the procedure cause an immediate, transient spike in serum PSA. **High-Yield Clinical Pearls for NEET-PG:** * **PSA Velocity:** An increase of **>0.75 ng/mL/year** is highly suggestive of malignancy, even if the absolute value is 25%** is more common in BPH. * **Wait Time:** After a digital rectal exam (DRE) or biopsy, wait at least **4–6 weeks** before measuring PSA to avoid false elevations.

Q: A patient with non-seminomatous tumor of the testis has more than 4 retroperitoneal lymph nodes involved. What is the appropriate management for this patient, considering the following treatment options, except one?

Radiotherapy. **Explanation:** The management of testicular tumors depends heavily on the histological type: **Seminoma** vs. **Non-Seminomatous Germ Cell Tumor (NSGCT)**. **Why Radiotherapy is the Correct Answer (The "Except" Option):** NSGCTs are inherently **radioresistant**. Unlike seminomas, which are highly radiosensitive and can be treated with radiation, NSGCTs do not respond predictably to radiotherapy. Therefore, it is not a standard treatment modality for NSGCT, regardless of the stage. **Analysis of Other Options:** * **Inguinal Orchiectomy (B):** This is the **gold standard initial step** for any suspected testicular mass. It provides the definitive histological diagnosis and local tumor control. It must always be performed via an inguinal approach to avoid scrotal lymph node seeding. * **Chemotherapy (C):** For advanced NSGCT (Stage IIB and above), platinum-based chemotherapy (e.g., BEP regimen: Bleomycin, Etoposide, Cisplatin) is the primary treatment. Involvement of >4 retroperitoneal nodes indicates significant metastatic burden (Stage IIB/C), making chemotherapy essential. * **RPLND (A):** This is a standard surgical intervention for NSGCT. It can be used as primary treatment for low-stage disease or as "Post-Chemo RPLND" to remove residual masses (>1 cm) after chemotherapy, as these may contain teratoma or viable tumor. **High-Yield Clinical Pearls for NEET-PG:** 1. **Tumor Markers:** NSGCT often shows elevated **AFP** and **beta-hCG**. Remember: **AFP is NEVER elevated in pure seminoma.** 2. **Lymphatic Spread:** Testicular tumors spread first to the **para-aortic (retroperitoneal) lymph nodes**, except if there is scrotal invasion (then to inguinal nodes). 3. **Treatment Rule:** Seminoma = Radio-sensitive; NSGCT = Chemo-sensitive/Radio-resistant. 4. **Most common NSGCT:** Mixed germ cell tumor.

Q: In which of the following conditions is a cystometric study indicated?

Neurogenic bladder. **Explanation:** **Cystometry** is the gold standard component of a urodynamic study (UDS) used to evaluate the pressure-volume relationship of the bladder during the filling phase. It measures bladder capacity, compliance, and the presence of involuntary detrusor contractions. **1. Why Neurogenic Bladder is Correct:** In neurogenic bladder (caused by spinal cord injury, diabetes, or multiple sclerosis), the coordination between the detrusor muscle and the urethral sphincter is lost. Cystometry is **essential** to classify the type of bladder dysfunction (e.g., detrusor hyperreflexia or areflexia) and to assess the risk of high-pressure storage, which can lead to upper renal tract damage (hydronephrosis). **2. Why Other Options are Incorrect:** * **Stress Incontinence:** Diagnosis is primarily clinical (demonstrating leakage with a cough/Valsalva). Urodynamics are usually reserved only if surgery is planned or if the diagnosis is unclear. * **Fistula:** Conditions like vesicovaginal fistula (VVF) are structural defects, not functional ones. Diagnosis is made via physical exam, dye tests (Moir’s test), or imaging (CT/IVP/Cystoscopy). * **Urge Incontinence:** Often diagnosed based on history (Overactive Bladder). While cystometry can show detrusor overactivity, it is not the first-line investigation unless conservative management fails. **Clinical Pearls for NEET-PG:** * **Normal Bladder Capacity:** 300–500 mL. * **First Sensation of Filling:** 150–250 mL. * **Compliance:** Calculated as $\Delta \text{Volume} / \Delta \text{Pressure}$. Low compliance is a hallmark of a "stiff" neurogenic bladder. * **Pdet (Detrusor Pressure):** Calculated as $P_{ves} (\text{intravesical}) - P_{abd} (\text{intra-abdominal})$. This distinguishes bladder contractions from abdominal straining.

Q: A 13-year-old male was brought to OPD with pain right side testes after being hit by a cricket ball 2 hours back. On examination, severe testicular pain and an absent cremasteric reflex. What is the next step?

Surgical exploration. ***Surgical exploration*** - This patient presents with **severe testicular pain** and **absent cremasteric reflex**, which has approximately **99% positive predictive value for testicular torsion** - The combination of these clinical findings constitutes a **surgical emergency** requiring **immediate scrotal exploration** without delay for imaging - **Time is critical**: testicular salvage rates are >90% if detorsion occurs within 6 hours, dropping to ~50% at 6-12 hours and <10% after 12 hours - In cases with **high clinical suspicion** (classic presentation with absent cremasteric reflex), imaging should **NOT delay surgical intervention** - Standard of care: proceed directly to the operating room for exploration and detorsion *USG Arterial Doppler* - While Doppler ultrasound can assess testicular blood flow, it is indicated only when the **diagnosis is equivocal** or clinical findings are unclear - Doppler has significant limitations: false negatives occur with intermittent or partial torsion, and arranging the study delays definitive treatment - In this case with **pathognomonic clinical findings** (absent cremasteric reflex + severe pain), imaging would inappropriately delay life-saving surgery - **"Time is testicle"** - every minute of delay reduces the chance of testicular salvage *USG Venous Doppler* - Venous Doppler is not the appropriate imaging modality for suspected testicular torsion - Arterial blood flow assessment is more relevant than venous drainage in diagnosing ischemia - However, with classic clinical presentation, neither imaging modality should delay surgical exploration *NSAIDS* - Administering analgesics alone is inappropriate management for suspected testicular torsion - Pain control does not address the underlying vascular compromise and will lead to **testicular loss** - NSAIDs may mask symptoms and create false reassurance while ischemic damage progresses

Q: In a follow-up case of prostate cancer, what do we need to check?

PSA. ***PSA***- **Prostate-Specific Antigen** is the primary biomarker used for routine surveillance and follow-up after definitive treatment (like prostatectomy or radiation) for prostate cancer. - A sustained rise in PSA levels, known as **biochemical recurrence**, is the earliest sign that prostate cancer may have returned locally or metastasized. *Alkaline phosphatase* - **Alkaline phosphatase (ALP)** levels are primarily followed when there is suspicion of **bony metastasis**, as high ALP reflects increased osteoblastic activity. - It is used to stage and evaluate advanced disease or monitor response to treatment for bone mets, but it is not the primary marker for general recurrence detection. *Testosterone* - **Testosterone** levels are monitored primarily in patients receiving **androgen deprivation therapy (ADT)** to ensure that castrate levels of androgens are being maintained. - Changes in circulating testosterone do not reliably indicate cancer recurrence or progression in patients not undergoing hormonal manipulation. *Acid phosphatase* - **Acid phosphatase (ACP)**, specifically prostatic acid phosphatase (PAP), is a historical tumor marker that has been superseded by PSA in nearly all aspects of follow-up. - Elevated ACP is usually associated with **advanced or metastatic disease** but lacks the sensitivity of PSA for detecting early biochemical recurrence.

Q: A 22-year-old male presents to the emergency department with a strong urge to urinate but is unable to do so. He has a history of perineal trauma. On examination, blood is noted at the external urethral meatus. Which structure is most likely injured?

Bulbar urethra. ***Bulbar urethra***- Perineal trauma, such as a **straddle injury**, typically compresses the **bulbar urethra** (part of the anterior urethra) against the inferior aspect of the pubic symphysis, leading to rupture or contusion.- The classic presentation of **blood at the external urethral meatus** combined with **urinary retention (inability to void)** following perineal trauma is pathognomonic for a suspected anterior urethral injury, most commonly involving the bulbar segment.*Posterior urethral valve*- This condition is a **congenital anomaly** causing obstruction almost exclusively in male **infants** and neonates, resulting in chronic hydronephrosis.- It is not a traumatic injury and therefore cannot explain the sudden onset of urinary retention in a 22-year-old male following **perineal trauma**.*Intraperitoneal Bladder rupture*- This type of rupture usually occurs due to blunt trauma to the **suprapubic region** when the bladder is full, leading to urine leakage into the abdominal cavity.- Although it causes inability to urinate and hematuria, the history of isolated **perineal trauma** and prominent **blood at the meatus** makes a primary urethral injury significantly more likely.*Membranous urethra*- The **membranous urethra** is part of the posterior urethra and its injury is highly associated with severe blunt trauma causing **pelvic fractures**.- Perineal or straddle injuries typically affect the **anterior urethra** (bulbar segment) because the posterior urethra is protected by the surrounding bony pelvis and supportive ligaments.

Question 1

An 85-year-old man underwent transurethral resection of the prostate. Histological examination of his specimen showed T1a stage adenocarcinoma. What is the appropriate management?

Accepted Answer

No further treatment

Answer

Endocrine therapy

Answer

Radical surgery

Answer

Hormone therapy

Question 2

What is the most common cause of urethral stricture?

Accepted Answer

Trauma

Answer

Infection

Answer

Congenital

Answer

Post endoscopy

Question 3

Which of the following conditions is NOT associated with an elevation in prostatic specific antigen?

Accepted Answer

Prostatic intraepithelial neoplasia

Answer

Acute prostatitis

Answer

Benign prostatic hyperplasia (BPH)

Answer

Prostatic needle biopsy

Question 4

A patient with non-seminomatous tumor of the testis has more than 4 retroperitoneal lymph nodes involved. What is the appropriate management for this patient, considering the following treatment options, except one?

Accepted Answer

Radiotherapy

Answer

Retroperitoneal Lymph Node Dissection (RPLND)

Answer

Inguinal orchiectomy

Answer

Chemotherapy

Question 5

Which of the following statement is false about hydrocele?

Accepted Answer

Wait for 5 years for spontaneous closure of congenital hydrocele

Answer

Arises due to patent processus vaginalis

Answer

Lord's plication of sac for small hydrocele

Answer

Jaboulay's eversion of sac for medium hydrocele

Question 6

In which of the following conditions is a cystometric study indicated?

Accepted Answer

Neurogenic bladder

Answer

Stress incontinence

Answer

Fistula

Answer

Urge incontinence

Question 7

A 13-year-old male was brought to OPD with pain right side testes after being hit by a cricket ball 2 hours back. On examination, severe testicular pain and an absent cremasteric reflex. What is the next step?

Accepted Answer

Surgical exploration

Answer

USG Venous Doppler

Answer

NSAIDS

Answer

USG Arterial Doppler

Question 8

In a follow-up case of prostate cancer, what do we need to check?

Accepted Answer

PSA

Answer

Acid phosphatase

Answer

Alkaline phosphatase

Answer

Testosterone

Question 9

A 22-year-old male presents to the emergency department with a strong urge to urinate but is unable to do so. He has a history of perineal trauma. On examination, blood is noted at the external urethral meatus. Which structure is most likely injured?

Accepted Answer

Bulbar urethra

Answer

Intraperitoneal Bladder rupture

Answer

Posterior urethral valve

Answer

Membranous urethra

Question 10

A 35-year-old man presents with severe left flank pain radiating to the groin for the past 3 days. Imaging reveals an 8 mm stone in the distal left ureter with moderate hydronephrosis. There is no evidence of urinary tract infection, and renal function is preserved. He has had no prior passage of this stone despite adequate hydration and analgesia, and his pain has been refractory to medical management with a failed trial of alpha-blocker therapy over 4 weeks. Which of the following is the recommended treatment for the ureteric stone shown in the image?

Accepted Answer

Ureteroscopy

Answer

Percutaneous nephrolithotomy

Answer

ESWL

Answer

Wait and watch

Urology — MCQs

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